Factors associated with access to palliative home care in palliative patients at Lampang Hospital.

BACKGROUND: Existing literature has shown the importance of palliative home care to improve quality of life among end-stage patients. However, access to palliative home care remains an issue. This study explores factors associated with successful delivery of palliative home care in palliative patients. METHODS: A retrospective study was conducted among patients who were referred to the palliative care team for consultation at Lampang Hospital from April 2020 to March 2021. Data from electronic medical records, including successful delivery of palliative home care, age, gender, public health insurance, admission department, primary disease (cancer, non-cancer), presenting symptoms (pain, dyspnea), palliative performance scale score and morphine use, were retrieved. Multiple logistic regression analysis was applied to explore the association, adjusting for covariates. RESULTS: A total of 370 patients were identified, with 88 (23.8%) receiving palliative home care. Results showed that being female, having low palliative performance scale score, morphine use, and having Civil Servant Medical Benefit Scheme insurance are associated with a higher chance of having access to palliative home care, compared with their counterparts. CONCLUSIONS: Results of this study pointed out health disparities among palliative patients who required palliative home care. This information can be in part used to redesign palliative home care system with the aim of improving access to care and patients' and caregivers' quality of life as a consequence.

Process evaluation protocol of a cluster randomised trial for a scalable solution for delivery of Diabetes Self-Management Education in Thailand (DSME-T).

INTRODUCTION: Type 2 diabetes mellitus is a major global challenge, including for Thai policy-makers, as an estimated 4 million people in Thailand (population 68 million) have this condition. Premature death and disability due to diabetes are primarily due to complications which can be prevented by good risk factor control. Diabetes Self-Management Education (DSME) programmes provide patients with diabetes with the necessary knowledge and skills to effectively manage their disease. Currently, a trial is being conducted in Thailand to evaluate the effectiveness, defined as HbA1c<7 at 12 months after enrolment, of a culturally tailored DSME in Thailand. A process evaluation can provide further interpretation of the results from complex interventions as well as insight into the success of applying the programme into a broader context. METHODS AND ANALYSIS: The aim of the process evaluation is to understand how and why the intervention was effective or ineffective and to identify contextually relevant strategies for future successful implementation. For the process evaluation, the design will be a mixed-method study collecting data from nurse providers, and village health volunteers (community health workers) as well as patients. This will be conducted using observations, interviews and focus groups from the three purposively selected groups at the beginning and end of trial. Quantitative data will be collected through surveys conducted at the beginning, during 6-month follow-up, and at the end of trial. The mixed-methods analysis will be triangulated to assess differences and similarities across the various data sources. The overall effectiveness of the intervention will be examined using multilevel analysis of repeated measures. ETHICS AND DISSEMINATION: Study approved by the Chiang Mai University Research Ethics Committee (326/2018) and the London School of Hygiene & Tropical Medicine (16113/RR/12850). Results will be published in open access, peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT03938233.

Scalable solution for delivery of diabetes self-management education in Thailand (DSME-T): a cluster randomised trial study protocol.

INTRODUCTION: Type 2 diabetes mellitus is among the foremost health challenges facing policy makers in Thailand as its prevalence has more than tripled over the last two decades, accounting for considerable death, disability and healthcare expenditure. Diabetes self-management education (DSME) programmes show promise in improving diabetes outcomes, but this is not routinely used in Thailand. This study aims to test a culturally tailored DSME model in Thailand, using a three-arm cluster randomised controlled trial comparing a nurse-led model, a peer-assisted model and standard care. We will test which model is effective and cost effective to improve cardiovascular risk and control of blood glucose among people with diabetes. METHODS AND ANALYSIS: 21 primary care units in northern Thailand will be randomised to one of three interventions, enrolling a total of 693 patients. The primary care units will be randomised (1:1:1) to participate in a culturally-tailored DSME intervention for 12 months. The three-arm trial design will compare effectiveness of nurse-led, peer-assisted (Thai village health volunteers) and standard care. The primary trial outcomes are changes in haemoglobin A1c and cardiovascular risk score. A process evaluation and cost effectiveness evaluation will be conducted to produce policy relevant guidance for the Thai Ministry of Public Health. The planned trial period will start in January 2020 and finish October 2021. ETHICS AND DISSEMINATION: Ethical approval has been obtained from Thailand and the UK. We will share our study data with other researchers, advertising via our publications and web presence. In particular, we are committed to sharing our findings and data with academic audiences in Thailand and other low-income and middle-income countries. TRIAL REGISTRATION NUMBER: NCT03938233.

Diagnostic accuracy of a urine dipstick for detecting albuminuria in hypertensive patients.

Background: Screening for albuminuria is generally recommended among patients with hypertension. While the urine dipstick is commonly used for screening urine albumin, there is little evidence about its diagnostic accuracy among these patients. This study aimed to assess the diagnostic accuracy of a dipstick in Thai hypertensive patients for detecting albuminuria. Methods: This study collected the data of 3,067 hypertensive patients, with the results of urine dipstick and urine albumin-to-creatinine ratio (ACR) from random single spot urine being examined in the same day at least once, at Lampang Hospital, Thailand, during 2018. For ACR, a reference standard of ≥ 30 mg/g was applied to indicate the presence of albuminuria. Results: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value of the trace result from dipsticks were 53.6%, 94.5%, 86.5%, and 75.5%, respectively. The area under the receiver operating characteristic curve of the dipstick was 0.748. Conclusion: Using the dipstick for screening albuminuria among hypertensive patients should not be recommended due to its low sensitivity. In response to high PPV, a trace threshold of the dipstick may be used to indicate presence of albuminuria.

From one-district-one-doctor to the inclusive track: Lessons learned from a 12-year special recruitment program for medical education in Thailand.

BACKGROUND: The One-District-One-Doctor (ODOD) medical education program was launched in 2005 with the purpose of increasing the production of rural doctors through special recruitment in Thailand. This article provides details of the ODOD program, together with its successes and challenges. Comparisons of the applied interventions between ODOD, the conventional rural recruitment program (Collaborative Project to Increase Production of Rural Doctors [CPIRD]), and the Inclusive track are also described. METHODS: Compared with the CPIRD program, additional interventions are applied to the ODOD program, including (1) recruitment from remote rural areas; (2) subsidized education in return for service; and (3) extended compulsory service in rural areas with a higher penalty fine. While ODOD students have shown a relatively high rural retention rate, the program challenges include low admission rate, adverse consequences from an extended compulsory service, restriction on specialist training, and high penalty fee. RESULTS: As a consequence of the program interventions, another special medical education program, the Inclusive track, was introduced as a replacement. Strategies through the Inclusive track to recruit students from remote rural areas are similar to those of ODOD. However, unlike ODOD, the Inclusive track has a reduced duration of compulsory service and penalty fine to match those of the standard requirements in the Normal track and CPIRD students. DISCUSSION: Building on past experience, the Inclusive track pursues a balance of pros and cons from the other medical production programs. Program evaluation and close monitoring will be crucial to measure the feedback from the Inclusive track to further improve the sustainability of long-term retention of rural physicians.

Community-based learning enhances doctor retention.

Background: Rural doctor shortage is a problem in many countries. Factors associated with doctor retention were reported such as colleagues, workload, accommodations, transportation, proximity of family and friends, incentives and career path. Rural background recruitment, increasing the quantity of doctor production to supply in rural and remote areas, and regulation are claimed to alleviate doctor scarcity in rural communities. Many programs have been developed, but an imbalance in physician distribution persists. Community-based learning (CBL) is recommended by the WHO to promote doctor retention. The longer contact time of CBL is practical, but it is uncertain that this results in greater retention. The objective of this study is to determine the association between contact time of CBL and retention of doctor with rural background recruitment. Methods: A cohort study was performed. The study population was 10,018 doctors graduated during 2001-2010 and followed up at least to 2014. Of the 10,018 physicians, 2098 doctors (21%) were recruited from rural backgrounds by the Collaborative Project to Increase Production of Rural Doctor (CPIRD). Contact time of CBL was calculated to the proportion of total curricular credit hours. The primary outcome was retention rate in government health-care system over 4 years. Statistical analysis was performed using multiple logistic regression. Results: A total of 5774 doctors (57.6%) were retained in the government health-care system. Higher percentages of CPIRD doctors were retained than normal track (72.1% and 53.8%, P < 0.001), especially in rural hospitals (60.3% and 38.4%, P < 0.001). Based on univariate analysis, CBL was slightly higher in retention than resignation group with statistical significance (2.97% and 2.90%, P = 0.045). Multiple logistic regression results showed that CBL, graduate entry, and geographic location of workplace were significantly associated with retention. Discussion: CBL can enhance doctor retention. It should incorporate meaningful experience such as rural exposure together with classroom teaching to focus concepts and integrating service to the community. Graduate entry and geographic location of workplace also have an impact on decision-making regarding retention.

Rural retention of new medical graduates from the Collaborative Project to Increase Production of Rural Doctors (CPIRD): a 12-year retrospective study.

Physician scarcity in rural areas is a major obstacle to healthcare access, leading to health inequity worldwide. In Thailand, a special recruitment program of medical education [Collaborative Project to Increase Production of Rural Doctors (CPIRD)] was initiated with four different medical training tracks. No previous research has examined the rural retention of new medical graduates across the CPIRD tracks, compared with those receiving conventional medical education (Normal track). This study examines the public retention of rural physicians from different tracks of entry. A retrospective study was conducted in new medical graduates who entered Ministry of Public Health (MoPH) hospitals from January 2003 to October 2014, and followed up until June 2015, using administrative data from the Personnel Administration Division, MoPH. The CPIRD registry database was used to identify physicians' tracks of entry. Survival analyses and multiple logistic regression analyses were applied to compare the annual retention and the probability of 3-year retention of rural physicians. Results clearly demonstrated a high rural retention of CPIRD medical graduates, compared with their Normal track peers, regarding both lower annual resignation (HR 0.456, P < 0.001) and higher 3-year retention (OR 2.441, CI: 2.192, 2.719). Some variations of rural retention were revealed across the different CPIRD tracks. Evidence from this study can be used as part of the information to reshape the physician production policy to reduce health inequity in rural areas.

Congestive heart failure in children with pneumonia and respiratory failure.

BACKGROUND: Congestive heart failure (CHF) is one of the most common cardiac complications of pneumonia in adulthood leading to increased risk of morbidity and mortality. Little is known, however, of CHF and pneumonia in children. The aim of this study was therefore to investigate the characteristics and factors associated with CHF in under-5 children with pneumonia and respiratory failure. METHODS: A retrospective cohort was conducted in hospitalized patients aged 2-59 months with community-acquired pneumonia and respiratory failure from June 2011 to June 2014 at Suratthani Hospital, Thailand. The characteristics, therapeutic strategy, and clinical outcomes of CHF were reviewed. Baseline characteristics and basic laboratory investigations on admission were compared between the CHF and non-CHF groups. RESULTS: Of 135 patients, 14 (10%) had CHF. Compared with patients without CHF, the CHF group had prolonged intubation and hospital stay and high rates of associated complications such as ventilator-associated pneumonia, sepsis, shock, and 30 day mortality. CHF was significantly associated with certain characteristics, including male sex and bacterial pneumonia. CONCLUSIONS: Pneumonia with respiratory failure is associated with CHF even in healthy children without cardiac risks. The awareness and early recognition of CHF, particularly in male, and bacterial pneumonia, is important in order to provide immediate treatment to reduce complications.

Assessing long-term QALYs gain from averting and reversing overweight and obesity in childhood.

BACKGROUND: Interventions to tackle childhood obesity have been devised in response to the rising prevalence of childhood obesity. However, efficiency of these interventions remains a concern. Cost-utility analysis, representing health benefits in terms of quality-adjusted life years (QALYs), is a type of economic evaluation that has widely been recommended in assessing efficiency of health interventions. However, certain limitations in using QALYs remain specifically difficult in QALYs estimation. This study estimates the long-term QALYs gain from reversing childhood obesity in Thailand. METHODS: An economic model was developed to estimate long-term QALYs of the youth aged 3-18 for the BMI status in childhood, which were categorized into three groups: normal weight, overweight, and obese. Long-term QALYs were estimated between ages 35 and 100, according to children's age, sex, and BMI status. Differences in QALYs between BMI status groups were calculated to represent the QALYs gain for youth from reversing obesity and overweight. The future outcomes were discounted at 3 % per annum in the base-case analysis; the discount rates of 0, 1.5, 3.5, and 5 % were also applied in the sensitivity analyses. RESULTS: QALYs gained from reversing childhood obesity increase with age, starting from 0.040 and 0.083 QALYs at age 3 to 0.590 and 0.553 QALYs at age 18 in boys and girls, respectively. Reversing overweight and obesity in girls produces more QALYs than in boys between ages 3 and 17. CONCLUSIONS: Efficiency is an important issue in allocating public healthcare resources to maximize social benefits. The results of this study facilitate long-term QALYs estimation with respect to BMI status in childhood, which could encourage more routine economic evaluation of child obesity interventions and maximize their health benefits.

International application of sugar-sweetened beverage (SSB) taxation in obesity reduction: factors that may influence policy effectiveness in country-specific contexts.

Sugar-sweetened beverage (SSB) taxation is becoming of increasing interest as a policy aimed at addressing the rising prevalence of obesity in many countries. Preliminary evidence indicates its potential to not only reduce obesity prevalence, but also generate public revenue. However, differences in country-specific contexts create uncertainties in its possible outcomes. This paper urges careful consideration of country-specific characteristics by suggesting three points in particular that may influence the effectiveness of a volume-based soft drink excise tax: population obesity prevalence, soft drink consumption levels, and existing baseline tax rates. Data from 19 countries are compared with regard to each point. The authors suggest that SSB or soft drink taxation policy may be more effective in reducing obesity prevalence where existing obesity prevalence and soft drink consumption levels are high. Conversely, in countries where the baseline tax rate is already considered high, SSB taxation may not have a noticeable impact on consumption patterns or obesity prevalence, and may incur negative feedback from the beverage industry or the general public. Thorough evaluation of these points is recommended prior to adopting SSB or soft drink taxation as an obesity reduction measure in any given country.

Cost-effectiveness of HPV vaccination compared with Pap smear screening on a national scale: a literature review.

Recommendations for worldwide use of human papillomavirus (HPV) vaccine are increasing. This study conducted a systematic review of articles related to cost-effectiveness analysis of wide-range HPV vaccination programs compared with Pap smear screening published before August 2007. Eight articles were identified using predefined inclusion and exclusion criteria. After excluding two outliers, the range of incremental cost-effectiveness ratios (ICERs) from six articles is between $16,600 and $27,231 per quality-adjusted life year (QALY) gained. The World Health Organization's guideline that compares incremental cost-effectiveness ratios (ICERs) with per capita Gross Domestic Product (GDP) was used to determine whether nation-wide application of HPV vaccine would be cost-effective. The HPV vaccination program is cost-effective in only 46 countries where per capita GDP is high. Further cost-effectiveness studies in developing and third-world countries are needed for making policy decisions.