Malaysian Primary Care Setting Research Articles

Implementing HLA-B*58:01 testing prior to allopurinol initiation in Malaysian primary care setting: A qualitative study from doctors' and patients' perspective.

Allopurinol, the first-line treatment for chronic gout, is a common causative drug for severe cutaneous adverse reactions (SCAR). HLA-B*58:01 allele was strongly associated with allopurinol-induced SCAR in Asian countries such as Taiwan, Japan, Thailand and Malaysia. HLA-B*58:01 screening before allopurinol initiation is conditionally recommended in the Southeast-Asian population, but the uptake of this screening is slow in primary care settings, including Malaysia. This study aimed to explore the views and experiences of primary care doctors and patients with gout on implementing HLA-B*58:01 testing in Malaysia as part of a more extensive study exploring the feasibility of implementing it routinely. This qualitative study used in-depth interviews and focus group discussions to obtain information from patients with gout under follow-up in primary care and doctors who cared for them. Patients and doctors shared their gout management experiences and views on implementing HLA-B*58:01 screening in primary care. Data were coded and analysed using thematic analysis. 18 patients and 18 doctors from three different healthcare settings (university hospital, public health clinics, private general practitioner clinics) participated. The acceptability to HLA-B*58:01 screening was good among the doctors and patients. We discovered inadequate disclosure of severe side effects of allopurinol by doctors due to concerns about medication refusal by patients, which could potentially be improved by introducing HLA-B*58:01 testing. Barriers to implementation included out-of-pocket costs for patients, the cost-effectiveness of this implementation, lack of established alternative treatment pathway besides allopurinol, counselling burden and concern about genetic data security. Our participants preferred targeted screening for high-risk populations instead of universal screening. Implementing HLA-B*58:01 testing in primary care is potentially feasible if a cost-effective, targeted screening policy on high-risk groups can be developed. A clear treatment pathway for patients who test positive should be made available.

Drug Utilisation Review among Geriatric Patients with Noncommunicable Diseases in a Primary Care Setting in Malaysia.

A prospective cross-sectional study was conducted to analyse the drugs prescribed to the elderly population with noncommunicable diseases and to determine the polypharmacy at a primary care clinic in Negeri Sembilan, Malaysia. The study was conducted for 6 months at the primary care clinic of Gemas. Geriatric patients above the age of 65 and diagnosed with noncommunicable diseases were included upon providing written informed consent. The majority of the geriatric patients were between 65 and 69 years (mean: 69.72 ± 2.85) and prescribed 4 or more medications (mean: 5.18 ± 0.64, p = 0.007). More than 95% (n = 295) of the geriatrics were found to have multimorbidity, in which around 45% (n = 139) had type-2 diabetes together with hypertension and dyslipidaemia. Combination therapy was prescribed to more than 97% (n = 302) of the elderly, whereas cardiovascular and endocrine medications were the most commonly prescribed. Ten prescriptions were found to have drug-related problems, prescribing cascade (80%), lack of medicine optimisation (10%), and inappropriate prescription (10%). In this study, the majority of the elderly had multimorbidity; polypharmacy was commonly seen among geriatric patients. Polypharmacy is the biggest threat to the elderly population, as it increases the chances of falls and fall-related injuries. Medicine optimisation and deprescribing will reduce the chances of drug-related problems and morbidity and mortality associated with polypharmacy and over-consumption of medications. Hence, the study recommends the health fraternity look for medication optimisation and deprescribing to reduce the future complications associated with polypharmacy.

Reducing Premature Coronary Artery Disease in Malaysia by Early Identification of Familial Hypercholesterolemia Using the Familial Hypercholesterolemia Case Ascertainment Tool (FAMCAT): Protocol for a Mixed Methods Evaluation Study.

Familial hypercholesterolemia (FH) is predominantly caused by mutations in the 4 FH candidate genes (FHCGs), namely, low-density lipoprotein receptor (LDLR), apolipoprotein B-100 (APOB-100), proprotein convertase subtilisin/kexin type 9 (PCSK9), and the LDL receptor adaptor protein 1 (LDLRAP1). It is characterized by elevated low-density lipoprotein cholesterol (LDL-c) levels leading to premature coronary artery disease. FH can be clinically diagnosed using established clinical criteria, namely, Simon Broome (SB) and Dutch Lipid Clinic Criteria (DLCC), and can be identified using the Familial Hypercholesterolemia Case Ascertainment Tool (FAMCAT), a primary care screening tool. This study aims to (1) compare the detection rate of genetically confirmed FH and diagnostic accuracy between the FAMCAT, SB, and DLCC in the Malaysian primary care setting; (2) identify the genetic mutation profiles, including novel variants, in individuals with suspected FH in primary care; (3) explore the experience, concern, and expectation of individuals with suspected FH who have undergone genetic testing in primary care; and (4) evaluate the clinical utility of a web-based FH Identification Tool that includes the FAMCAT, SB, and DLCC in the Malaysian primary care setting. This is a mixed methods evaluation study conducted in 11 Ministry of Health primary care clinics located at the central administrative region of Malaysia. In Work stream 1, the diagnostic accuracy study design is used to compare the detection rate and diagnostic accuracy of the FAMCAT, SB, and DLCC against molecular diagnosis as the gold standard. In Work stream 2, the targeted next-generation sequencing of the 4 FHCGs is used to identify the genetic mutation profiles among individuals with suspected FH. In Work stream 3a, a qualitative semistructured interview methodology is used to explore the experience, concern, and expectation of individuals with suspected FH who have undergone genetic testing. Lastly, in Work stream 3b, a qualitative real-time observation of primary care physicians using the "think-aloud" methodology is applied to evaluate the clinical utility of a web-based FH Identification Tool. The recruitment for Work stream 1, and blood sampling and genetic analysis for Work stream 2 were completed in February 2023. Data collection for Work stream 3 was completed in March 2023. Data analysis for Work streams 1, 2, 3a, and 3b is projected to be completed by June 2023, with the results of this study anticipated to be published by December 2023. This study will provide evidence on which clinical diagnostic criterion is the best to detect FH in the Malaysian primary care setting. The full spectrum of genetic mutations in the FHCGs including novel pathogenic variants will be identified. Patients' perspectives while undergoing genetic testing and the primary care physicians experience in utilizing the web-based tool will be established. These findings will have tremendous impact on the management of patients with FH in primary care and subsequently reduce their risk of premature coronary artery disease. DERR1-10.2196/47911.

Healthcare resources, organisational support and practice in asthma in six public health clinics in Malaysia

Asthma, a common chronic respiratory illness is mostly managed in primary care. We aimed to determine healthcare resources, organisational support, and doctors’ practice in managing asthma in a Malaysian primary care setting. A total of six public health clinics participated. We found four clinics had dedicated asthma services. There was only one clinic which had a tracing defaulter system. Long-term controller medications were available in all clinics, but not adequately provided. Resources, educational materials, and equipment for asthma management were present, though restricted in number and not placed in main locations of the clinic. To diagnose asthma, most doctors used clinical judgement and peak flow metre measurements with reversibility test. Although spirometry is recommended to diagnose asthma, it was less practiced, being inaccessible and unskilled in using as the main reasons. Most doctors reported providing asthma self-management; asthma action plan, but for only half of the patients that they encountered. In conclusion, there is still room for improvement in the provision of clinic resources and support for asthma care. Utilising peak flow metre measurement and reversibility test suggest practical alternative in low resource for spirometry. Reinforcing education on asthma action plan is vital to ensure optimal asthma care.

Respiratory microorganisms in acute pharyngitis patients: Identification, antibiotic prescription patterns and appropriateness, and antibiotic resistance in private primary care, central Malaysia.

Acute pharyngitis (AP) is a common reason for private primary care consultations, thus providing an avenue for widespread antibiotic intake among the community. However, there is limited data on the antibiotic prescription appropriateness and resistance information in the Malaysian private primary care setting, therefore, this study aimed to investigate the prevalence of isolated viruses and bacteria, antibiotic resistance patterns, antibiotic prescription patterns and appropriateness by general practitioners (GPs) and factors affecting antibiotic resistance and antibiotic prescription patterns. To investigate, a cross-sectional study was conducted among 205 patients presenting with AP symptoms at private primary care clinics in central Malaysia from 3rd January 2016 to 30th November 2016. Throat swabs were collected from 205 AP patients for two purposes: (i) the detection of four common respiratory viruses associated with AP via reverse-transcription real-time PCR (qRT-PCR); and (ii) bacterial identification using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Bacterial isolates were then subjected to antibiotic susceptibility screening and McIsaac scoring was calculated post-prescription based on GP selection of criteria. Generalized estimating equations analysis with multiple logistic regression was conducted to identify factors associated with presence of virus and antibiotic prescription. The results showed that 95.1% (195/205) of patients had at least one of the four viruses, with rhinovirus (88.5%) being the most prevalent, followed by adenovirus (74.9%), influenza A virus (4.6%) and enterovirus (2.1%). A total of 862 non-repetitive colonies were isolated from the culture of throat swabs from 205 patients who were positive for bacteria. From a total of 22 genera, Streptococcus constitutes the most prevalent bacteria genus (40.9%), followed by Neisseria (20%), Rothia (13.0%), Staphylococcus (11%) and Klebsiella (4.9%). Only 5 patients carried group A beta-hemolytic streptococci (GABHS). We also report the presence of vancomycin-resistant S. aureus or VRSA (n = 9, 10.1%) among which one isolate is a multidrug-resistant methicillin-resistant S. aureus (MDR-MRSA), while 54.1% (n = 111) were found to carry at least one antibiotic-resistant bacteria species. Application of the McIsaac scoring system indicated that 87.8% (n = 180) of patients should not be prescribed antibiotics as the majority of AP patients in this study had viral pharyngitis. The antibiotic prescription appropriateness by applying post-prescription McIsaac scoring was able to rule out GABHS pharyngitis in this sample with a GABHS culture-positive sensitivity of 40% (n = 2/5) and specificity of 90% (180/200). In conclusion, antibiotic-resistant throat isolates and over-prescription of antibiotics were observed and McIsaac scoring system is effective in guiding GPs to determine occurrences of viral pharyngitis to reduce unnecessary antibiotic prescription.

Prevalence of Good Condom Usage and Its Association with Condom Use Self-Efficacy among Youth Attending HIV/STDs Clinics in Primary-Care Settings in Malaysia.

The low prevalence of condom usage among youth with Human Immunodeficiency Virus/Sexually Transmitted Diseases (HIV/STDs) is a concern. Condom use self-efficacy has been identified as a significant predictor of condom usage. This cross-sectional study examines the prevalence of good condom usage and its association with condom use self-efficacy among Malaysian urban youth, aged between 18 to 24 years old attending HIV/STDs clinics in primary-care settings, Selangor. Utilising the Harmonised Malay version of Condom Use Self-Efficacy Scale (CUSES M-H) questionnaire, the data from 218 responders were analysed using univariate and multiple logistic regression. The prevalence of good condom usage was 61% (95% CI: 54%, 68%). The average mean score of condom use self-efficacy was 3.07. Condom use self-efficacy was divided into four subscales of mechanics, perceived barriers, assertiveness and intoxicants. The assertiveness subscale had the highest average mean score of 3.42, while the intoxicant subscale score had the lowest average mean score of 2.24. Good condom usage was significantly associated with condom use during first sexual intercourse (aOR = 5.81, 95% CI: 1.97, 17.14), duration diagnosis of HIV/STDs of more than 12 months (aOR = 6.40, 95% CI: 2.30, 17.86) and the high assertiveness subscale score (aOR = 1.19, 95% CI: 1.03, 1.36). A behavioural change campaign that targets high-risk youth in primary care settings could promote condom use self-efficacy particularly assertiveness to increase condom usage among the youth.

A Qualitative Exploration of the Acceptability of an Online Web Application to Promote Breast and Cervical Cancer Screening in Primary Care Settings in Malaysia

PURPOSE In Malaysia, breast and cervical are the most common and third most common cancers respectively. They are associated with high morbidity and mortality in women. With the rapid development of information communication technology and widespread adoption of mobile devices in low to middle-income countries, online web applications (app) could be one of the strategies to engage patients to go for screening programs. METHODS Fifteen (15) health care professionals (HCPs) and 25 patients visiting the primary care were interviewed through focus groups and in-depth interviews to determine the acceptability of an online web application to promote screening for these cancers. RESULTS Both HCPs and patients expressed that an online web app would be beneficial to the technology-savvy group such as the younger generation. However, the older-aged group could benefit from it with some assistance. The primary consideration identified is the user's information technology (IT) competency. Participants suggested that the use of easy-to-use features (eg, download method), visually easy-to-understand formats (eg, less text and more pictures, videos), and provision of support to navigate the web app may be critical to ensure good uptake of a web app on screening. Contents of the app suggested to be included were: individual risk assessment for the users of the app, benefits of screening, information addressing patients' barriers such as fear, embarrassment, logistic, and cost issues. CONCLUSION The findings of our study may be useful as a guide to developing an online web app to promote breast and cervical cancer screening.

Antibiotic Prescribing Patterns for Patients with Pharyngitis in Malaysian Public Primary Care Clinics.

BackgroundOver-prescription of antibiotics for upper respiratory tract infection (URTI) is a continuing problem in Malaysia, leading to increased antimicrobial resistance and unnecessary cost incurred for treatment. In a patient presenting with a sore throat, it is recommended to only prescribe antibiotics to group A streptococcus (GAS) pharyngitis confirmed by a throat culture, rapid antigen test or in patients with a Centor score of 4.MethodsThis cross-sectional study assessed the proportion of antibiotics prescribed and antimicrobial susceptibility patterns of GAS pharyngitis in the Malaysian primary care setting. Two-hundred and fifteen adult patients presenting with sore throat were recruited in three primary care clinics. Demographic data and clinical information were collected and analysed. Centor scores were calculated according to the clinical information and throat swabs were collected from all participants for GAS identification.ResultsOnly six throat swabs isolated GAS and indicated for antimicrobial treatment (2.8%). However, 48 participants (22.3%) were prescribed antibiotics out of which only four (8.3%) patients with isolated GAS, including three (6.2%) patients who clinically had a Centor score of 4 and one patient with a score of 3. Amoxicillin and erythromycin were the most commonly prescribed antibiotics (58.3% and 25% of all antibiotics, respectively).ConclusionThere is a high proportion of antibiotic prescriptions which were not indicated in patients with sore throat in this study. This may reflect a common practice of antibiotic overuse for sore throat in primary care settings in Malaysia. Concerted interventions to reduce the inappropriate prescribing of antibiotics are urgently needed.

The Intention and Uptake of Colorectal Cancer Screening after a Brief Health Education Program in a Malaysian Primary Care Setting: A Population-Based Study.

Colorectal cancer (CRC) is the most common cancer in men and the second most common cancer in women in Malaysia. A major challenge for CRC screening programs is to improve the screening participation rates. In Malaysia, the most critical barrier to the uptake of CRC screening is the lack of patient awareness. This study aimed to determine the intention and the uptake of CRC screening, and to explore the related motivators and barriers after raising awareness with a brief health education. Methods:An analytical cross-sectional study was conducted in a government health clinic of Penang from March to August 2019. Asymptomatic clinic attendees aged 50-75 years who had no prior awareness of CRC screening were recruited by systematic random sampling technique. Participants first received a standardised one to one health education, followed by an interview using a standardised questionnaire to assess their CRC screening intention and the relevant motivators and barriers. A submission of a sample for immunochemical faecal occult blood test (iFOBT) was considered as an uptake of the CRC screening. Results:A total of 546 participants participated in this study. The mean age of the participants was 62.8 (SD=6.36). Majority of them were females (57.3%), Chinese (78.6%), who had attained primary or higher education (92.0%) and had comorbidities (87.0%). After a brief health education, 231 participants (42.3%) agreed to undergo iFOBT. The actual screening uptake rate in this study was 28%. Perceived benefit of the test (84.4%) was the most common motivators, while self-perceived non-vulnerability was the biggest impediment to CRC screening intention. Physicians’ recommendation was the perceived most effective way in raising CRC awareness. Conclusion: Participants prefer physicians to provide health education. Standardised brief health education is inadequate to stimulate CRC screening adherence. Future interventions will require in-depth understanding of patients’ beliefs, risk perception, and affective responses.

Gender disparity in the prescription of secondary prevention medications in a Malaysian primary care clinic.

Cardiovascular disease is the leading cause of death worldwide. Despite the proven benefit of secondary prevention medications (SPMs), their utilisation remains suboptimal in many countries. This study aimed to assess the use of SPMs in a Malaysian primary care clinic and factors associated with it. A retrospective review of electronic medical records was conducted to assess the prescription of SPMs among patients with coronary artery disease who attended the clinic between 1st January 2018 and 31st December 2018. Prescriptions of SPMs were documented in numbers and percentages. Multiple logistic regressions were used to analyse factors associated with the prescription of SPMs. Of the 662 patients included in the study, 99.1% were prescribed statins, 97% antiplatelets, 81.7% angiotensin-converting enzyme (ACE)-inhibitors or angiotensin II receptor blockers (ARBs), and 78.7% beta-blockers. Male patients were more likely to be prescribed statins (OR = 8.584, 95% CI: 1.431 - 51.510) and antiplatelets (OR = 6.818, 95% CI: 2.294 - 20.257). Another significant factor for antiplatelets prescription was having diabetes (OR = 3.318, 95% CI: 1.148 - 9.590). Having hypertension was associated with ACE-inhibitors or ARBs prescription (OR = 4.008, 95% CI: 2.522 - 6.370). Although the majority of patients received SPMs, there were significant disparities for some SPMs prescriptions among female patients. As these medications are widely available in the Malaysian primary care setting, steps should be taken to ensure that these medications are prescribed equally for all eligible patients.

Factors associated with improper metered-dose inhaler technique among adults with asthma in a primary care clinic in Malaysia.

Metered-dose inhalers (MDI) are the most used inhalers worldwide. However, improper MDI techniques remain a significant problem and cause uncontrolled asthma. Studies worldwide have reported that the causes of inefficient inhaler technique are multifactorial. However, this topic has been less well studied in the Asian population. This study aimed to evaluate the MDI technique and associated factors among adults with asthma in a primary care setting in Malaysia. This was a cross-sectional study with universal sampling conducted between July and October 2017. A total of 146 patients with asthma aged 18 years and older in a primary care clinic in Putrajaya, Malaysia were recruited. Logistic regressions were used for statistical analysis to examine the association between improper MDI techniques and their related factors. The majority (83%) of respondents were female with a median age of 37 (IQR = 30.75-49.25) years, and the median duration of asthma of 20 (IQR = 10-30) years. An improper MDI technique was observed in 100 (71.9%) patients. The most frequently missed step was exhaling gently and fully before inhalation (51.4%). Respondents who were not on an MDI preventer (adjusted OR: 2.487, 95% CI: 1.121-5.519, p = 0 .025) or had used an MDI 5 years or fewer (adjusted OR: 3.369, 95% CI: 1.425-7.964, p = 0.006) were more likely to employ an improper MDI technique. There was a high proportion of improper MDI techniques among patients with asthma. Patients not using an MDI preventer or who had used an MDI less than 5 years were at higher risk of improper MDI technique.

Clinician perceptions of common mental disorders before and after implementation of a consultation-liaison psychiatry service: a longitudinal qualitative study in government-operated primary care settings in Penang, Malaysia

ObjectivesTo explore primary care clinician perceptions of barriers and facilitators in delivering care for common mental disorders (CMD) before and after implementation of a consultation-liaison psychiatry service (Psychiatry in Primary...

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.

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.
 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.
 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<0.001); performing foot examination (2.4% vs. 0.6%, p<0.001); performing funduscopy/fundus photography (1.5% vs. 0.3%, p<0.001); monitoring renal profile (0.9% vs. −0.6%, p=0.001); measuring urine protein (1.2% vs. 0.6%, p<0.001), and giving lifestyle modification and self-management advice (1.2% vs. −0.3%, p<0.001) in the intervention versus control groups, respectively.
 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.
 TRIAL REGISTRATION: Registered with: ClinicalTrials.gov: NCT01545401. Date of registration: 1st March 2012.

Prescribing patterns of antihypertensive medications and blood pressure control among hypertensive patients in a primary care setting in Malaysia

Aims: This study aims to describe the prescribing patterns of antihypertensive medications and short term outcomes of these patients, defined as repeat blood pressure measurements by a medical professional within 6 months, in a primary care facility in Puchong, located within the state of Selangor in Malaysia. Methods: This study was a cross-sectional, retrospective analysis of patients with essential hypertension, aged 18 and above, with blood pressure recorded at least twice within a 6-month period in an urban primary care clinic in Malaysia. Patients with history of co-morbidities were excluded. The prescribing patterns of antihypertensive medications and proportion of patients who achieved blood pressure control of less than 140/90 mmHg were ascertained. Results: A total of 200 prescriptions were analysed, including 52.5% females taking a mean of 1.7 (0.7) antihypertensive medications with a mean age of 57.9 (12.4) years. Most of the patients were prescribed either a single medication (n=90, 45.0%) or two medications (n=90; 45.0%) to control their blood pressure. Only 20 patients (10.0%) were prescribed three antihypertensive medications. A total of 127 (63.5%) patients met the blood pressure target of less than 140/90 mmHg. All participants exhibited a significant drop in systolic blood pressure, reducing from 143.0 (16.0) mmHg at baseline to 135.3 (14.8) mmHg at the end of 6 months (p<0.001). Diastolic blood pressure also decreased significantly from 83.5 (11.7) mmHg at baseline to 79.0 (10.2) mmHg at the end of 6 months (p<0.001). The choice of antihypertensive medications by the prescribers was compliant with the hypertension guidelines of Malaysia. Conclusion: The most commonly prescribed antihypertensive class was calcium channel blockers. Significant reduction in blood pressure was observed in patients from baseline to the follow-up visit. Further research of larger sample size and longer monitoring period is necessary to provide more robust epidemiology and drug utilisation data.

High-risk nonsteroidal anti-inflammatory drugs prescribing in primary care: results from National Medical Care Survey Malaysia.

Background Information on the extent of high-risk prescribing for nonsteroidal anti-inflammatory drugs (NSAIDs) across developing countries is scarce. Objectives This study examines the prescribing pattern for NSAIDs in primary care, assesses the extent of high-risk NSAIDs prescribing and identifies associated factors. Setting 129 public and 416 private primary care clinics in Malaysia. Methods Data were derived from the National Medical Care Survey 2014, a cross-sectional survey on primary care morbidity patterns and clinical activities in Malaysia. Types of NSAIDs, indications for NSAIDs use and proportion of high-risk NSAIDs prescribing were assessed. Factors associated with high-risk NSAIDs prescribing were identified with a multivariable logistic regression. Weighted results, adjusted for sampling design and non-response were presented. Main outcome measures Prescribing pattern of NSAIDs, proportion of high-risk NSAIDs prescribing and its associated factors. Results Among the 55,489 patients who received NSAIDs, diclofenac was the most frequently prescribed NSAID (40.5%, 95% CI 40.1-40.9%), followed by mefenamic acid (29.2%, 95% CI 28.8-29.6%). The commonest indications for NSAIDs use were musculoskeletal condition and respiratory tract infection, both at 17.8% (95% CI 17.4-18.1%). A total of 22.9% (95% CI 22.6-23.3%) patients received high-risk NSAID prescriptions. Of these, 47.8% (95% CI 46.9-48.7%) did not receive adequate gastroprotection despite being at risk, 24.8% (95% CI 24.0-25.5%) were prescribed NSAIDs despite having cardiovascular comorbidities and 22.4% (95% CI 21.7-23.2%) were prescribed high-dose NSAIDs. The odds of receiving high-risk NSAID prescriptions increased with the number of drugs prescribed (OR 1.23, 95% CI 1.06-1.43) and the number of diagnoses in one visit (OR 2.21, 95% CI 1.71-2.86). The odds of being prescribed high-risk NSAID prescriptions were lower in patients with secondary (OR 0.52, 95% CI 0.35-0.77) and tertiary education (OR 0.39, 95% CI 0.22-0.68) compared to patients without formal education. Patients' citizenship, indication for NSAID prescriptions and whether a medical certificate was issued were also significantly associated with the likelihood of receiving high-risk NSAID prescriptions. Conclusions A quarter of NSAIDs prescribed in Malaysian primary care setting is categorised as high-risk prescribing. Targeted strategies are necessary to improve patient safety.

Factors Associated with High Patient Activation Level among Individuals with Metabolic Syndrome at a Primary Care Teaching Clinic.

Background: High activation level has been associated with higher education background, better self-rated health status, and having adequate health literacy. However, there is a gap in the literature regarding the level of activation and the factors associated with it among patients with metabolic syndrome (MetS) in the Malaysian primary care setting. Objectives: This study aims to determine activation levels and the factors associated with high activation among individuals with MetS in primary care. Methods: A cross-sectional study was conducted at a university primary care clinic. Patient activation was measured using the Patient Activation Measure®–13 Malay version. Activation levels were dichotomized into “low activation” (levels 1 and 2) and “high activation” (levels 3 and 4). To determine the factors associated with high activation, simple logistic regressions (SLogR) followed by multiple logistic regressions (MLogR) were performed. Results: Of 333 participants, 280 (84.1%) were included in the final analysis. The mean activation score was 59.4 (SD ±10.20) and 61.8% had high activation level. Two variables were found to be significant on MLogR. Those who were employed have the odds of 3.135 (95% CI 1.442-6.816) of having high activation compared with those who were unemployed. Those with good self-reported health status have the odds of 6.482 (95% CI 1.243-33.792) of having high activation compared to those with poor self-reported health status. Conclusions: The majority of participants had high activation levels. Those who were employed and those who had good self-reported health status were more likely to have high activation levels. Findings of this study could be used to develop patient activation interventions to improve self-management skills among individuals with MetS in primary care. These may include problem solving support, individualized care plans, peer or family support, and skill building. Those in high activation group can be trained to become mentors to support their peers who have low activation level.

75 Functional Mobility and Balance Confidence as Correlates of Fall Risk in Older Adults Attending a Primary Health Care Clinic

Abstract Background Fall is one of the leading cause of unintentional injury among older adults. Information regarding functional mobility and balance confidence as correlates of fall risk in older adults attending a primary health care clinic is limited. This information is vital for fall screening and prevention. We aimed to examine if functional mobility and balance confidence were correlates of fall risk in older adults attending a primary health care clinic. Methods 106 older adults (≥60 years old) attending a primary health care clinic at Cheras, Malaysia participated in this cross-sectional study. Socio-demographic details and falls history were obtained using a structured questionnaire. Functional mobility and balance confidence were assessed using Timed Up and Go (TUG) test and Activities-Specific Balance Confidence (ABC) scale respectively. Fallers were categorised based on history of at least a fall in the past 12 months. Differences between faller and non-faller groups were distinguished using Independent T and Mann Whitney tests. Binomial logistic regression and receiver operating curve were performed to identify if functional mobility and balance confidence were correlates of falls risk and the cut off values for measures were obtained. Results TUG test and ABC scores differed significantly between the two groups (p< 0.05). Both TUG test and ABC scale were identified as correlates of falls risk with r, R2 of 0.98, 0.26 (p< 0.001) and 0.95, 0.12 (p< 0.05) respectively. Cut off value of 9.02 seconds and above for TUG test and 82.81% and below for ABC score were identified as risk factor of falls among older adults. Conclusion The cut off values obtained from our study can be used as reference to screen older adults at risk of falls in Malaysian primary health care settings. Early fall risk screening and management is a part of falls prevention strategy in older adults.

Pharmacist-led academic detailing improves statin therapy prescribing for Malaysian patients with type 2 diabetes: Quasi-experimental design.

ObjectivePrevious reports have highlighted the suboptimal utilization and prescription of statin therapy among patients with type 2 diabetes mellitus (T2DM) in the Malaysian clinical practice. This study aims to test the impact of a pharmacist-led academic detailing program on improving the overall statin therapy prescribing in Malaysian hospital and primary care settings.MethodsAs a quasi-experimental design with a control group and pre-tests., we examined 1,598 medical records of T2DM subjects in six healthcare facilities in the state of Pahang, Malaysia. In all study sites, there was a pre and post-intervention assessment of the percentage of appropriate statin therapy prescribing that complied with the clinical guidelines with no potential safety issues. The intervention was an academic detailing program offered to the health care providers in three study sites, while the other three sites served as the control group. A comparison of the overall percentage of appropriate statin therapy prescribing before and after the academic detailing was performed in all intervention and control sites.ResultsOverall, 797 medical records were examined in the pre-intervention phase, and 801 records were evaluated in the post-intervention phase. The academic detailing program was associated with a statistically significant difference in the proportion of appropriate statin therapy prescribing between the post-intervention phase compared to the pre-intervention phase (n = 246, 61.7% versus n = 188, 47.1%), p = 0.001. Whereas, the appropriate statin therapy prescribing in the control study sites experienced a modest change from 53.8% (214/398) to 56.7% (228/402), p = 0.220. The academic detailing showed significant increases in the proportions of appropriate statin therapy prescribing in both hospital and primary care settings.ConclusionsThe academic detailing program was found to be significantly associated with a positive impact on the overall statin therapy prescribing among patients with T2DM in Malaysian hospital and primary care settings.

Diabetes empowerment scores among type 2 diabetes mellitus patients and its correlated factors: A cross-sectional study in a primary care setting in Malaysia.

BACKGROUNDThere are limited studies on diabetes empowerment among type 2 diabetes patients, particularly in the primary care setting.AIMTo assess the diabetes empowerment scores and its correlated factors among type 2 diabetes patients in a primary care clinic in Malaysia.METHODSThis is a cross sectional study involving 322 patients with type 2 diabetes mellitus (DM) followed up in a primary care clinic. Systematic sampling method was used for patient recruitment. The Diabetes Empowerment Scale (DES) questionnaire was used to measure patient empowerment. It consists of three domains: (1) Managing the psychosocial aspect of diabetes (9 items); (2) Assessing dissatisfaction and readiness to change (9 items); and (3) Setting and achieving diabetes goal (10 items). A score was considered high if it ranged from 100 to 140. Data analysis was performed using SPSS version 25 and multiple linear regressions was used to identify the predictors of total diabetes empowerment scores.RESULTSThe median age of the study population was 55 years old. 56% were male and the mean duration of diabetes was 4 years. The total median score of the DES was 110 [interquartile range (IQR) = 10]. The median scores of the three subscales were 40 with (IQR = 4) for “Managing the psychosocial aspect of diabetes”; 36 with (IQR = 3) for “Assessing dissatisfaction and readiness to change”; and 34 with (IQR = 5) for “Setting and achieving diabetes goal”. According to multiple linear regressions, factors that had significant correlation with higher empowerment scores among type 2 diabetes patients included an above secondary education level (P < 0.001), diabetes education exposure (P = 0.003), lack of ischemic heart disease (P = 0.017), and lower glycated hemoglobin (HbA1c) levels (P < 0.001).CONCLUSIONDiabetes empowerment scores were high among type 2 diabetes patients in this study population. Predictors for high empowerment scores included above secondary education level, diabetes education exposure, lack of ischemic heart disease status and lower HbA1c.