A cost-effectiveness analysis of national smoking cessation services among chronic obstructive pulmonary disease patients in Thailand.

AIMS: Thailand's national smoking cessation services (FAH-SAI clinics) were founded in 2010. A cost-effectiveness analysis (CEA) is needed to inform policymakers of the allocation and prioritization of the limited budget to maximize the value for money of reimbursing these services. Chronic obstructive pulmonary disease (COPD) patients would benefit from smoking cessation services. Therefore, this study aimed to assess the cost-effectiveness of these multidisciplinary services compared to the usual care among COPD patients in Thailand from a societal perspective. METHODS: We conducted a CEA from a societal perspective using a Markov model to simulate lifetime costs and quality-adjusted life years (QALYs) gained by each smoking cessation intervention over the patient's lifetime. We derived the effectiveness of the smoking cessation services from a multicenter, longitudinal study of smoking cessation services in Thailand and estimated the natural quit rate, transition probabilities, health utility, and cost data from the published literature. Costs and outcomes were discounted at 3%. Sensitivity analyses were performed. RESULTS: Compared to the usual care, FAH-SAI clinics were associated with higher costs (4,207 THB (US$133)) and improved QALYs (0.11), with an incremental cost-effectiveness ratio of 37,675 THB/QALY (US$1,187/QALY). The effectiveness of FAH-SAI clinics was a key driver of the cost-effectiveness results. At the willingness-to-pay (WTP) threshold of 160,000 THB (US$5,042) per QALY gained, the probability of being cost-effective was 96.5%. CONCLUSIONS: FAH-SAI clinics were cost-effective under Thailand's WTP threshold. Our results could inform policymakers in allocating resources to support smoking cessation services for COPD patients in Thailand.

Cost-effectiveness analysis of the SMART quit clinic program in smokers with cardiovascular disease in Thailand.

INTRODUCTION: The SMART Quit Clinic Program (FAHSAI Clinic) has been implemented in Thailand since 2010; however, it remains unclear whether the benefits gained from this program justify its costs. We assessed its cost-effectiveness compared to usual care in a population of Thai smokers with cardiovascular disease (CVD) from a societal perspective. METHODS: We conducted a cost-utility analysis using a Markov model to simulate lifetime costs and quality-adjusted life years (QALYs) of Thai smokers aged ≥35 years receiving smoking cessation services offered from FAHSAI Clinic or usual care over a horizon of 50 years. The model used a 6-month continuous abstinence rate from a multicenter prospective study of 24 FAHSAI Clinics. A series of sensitivity analyses including probabilistic sensitivity analysis were conducted to assess robustness of study findings. Cost data are presented in US$ for 2020. RESULTS: The FAHSAI Clinic was dominant as it was less costly ($9537.92 vs $10964.19) and more effective (6.06 vs 5.96 QALYs) compared with usual care over the 50-year time horizon. Changes in risks of stroke and coronary heart disease among males had the largest impact on the cost-effectiveness findings. The probability that FAHSAI Clinic was cost-effective was 99.8% at a willingness-to-pay threshold of $5120. CONCLUSIONS: The FAHSAI Clinic smoking cessation program was clinically superior and cost-saving compared to usual care for Thai patients with CVD in all scenarios. A budget impact analysis is needed to estimate the financial impact of adopting this program within the Thai healthcare system.

Assessment of the real-world impact of the Thai smoking cessation programme on clinical outcomes: protocol for a multicentre prospective observational study.

BACKGROUND: Tobacco smoking is the most common preventable cause of morbidity and mortality in the world. In an effort to counteract the harmful consequences of smoking, various tobacco control measures have been implemented, including the use of smoking cessation programmes to reduce the number of new smokers as well as helping current smokers to quit smoking. In Thailand, the SMART Quit Clinic Program (FAH-SAI Clinics) was launched in 2010 to provide smoking cessation services by a multidisciplinary team. There are currently 552 FAH-SAI Clinics established across all 77 provinces of Thailand. AIM: This protocol describes a study aiming to evaluate the SMART Quit Clinic Program (FAH-SAI Clinics) in terms of programme performance and clinical outcomes. We hope that the results of the study could be used to improve the current service model and the programme's success. METHOD: A multicentre prospective observational study will be conducted. The study will focus on 24 FAH-SAI Clinics across 21 provinces of Thailand. The primary outcomes are seven-day point prevalence abstinence rate and continuous abstinence rate at three and six months. The outcomes will be measured using a self-reported questionnaire and biochemical validated by exhaled carbon monoxide. DISCUSSION: This study will be the first real-world study that reports the effectiveness of the well-established smoking cessation programme in Thailand. Findings from this study can help improve the quality of smoking cessation services provided by multidisciplinary teams and other smoking cessation services, especially those implemented in low- and middle-income countries.

The impact of Thai multidisciplinary smoking cessation program on clinical outcomes: A multicentre prospective observational study.

Introduction: Tobacco use is the leading preventable cause of morbidity and mortality worldwide. Since 2010, Thailand has implemented a multidisciplinary smoking cessation clinic, which provides smoking cessation services, but the effectiveness of the clinics was not formally evaluated. This study was conducted to assess the real-world effectiveness of this multidisciplinary smoking cessation program. Methods: We conducted a prospective, multicentre, observational study on Thai participants aged 13 years and older in 24 smoking cessation clinics across Thailand's 13 health regions. Each clinic offered smoking cessation interventions according to the well-established 5As model for smoking cessation (Ask, Advise, Assess, Assist, and Arrange). Outcomes of interest were continuous abstinence rates (CAR) at 3 and 6 months. Biochemical confirmation and self-reporting were used to assess the outcomes. Descriptive statistics (mean, SD, median, IQR, and percentage) were used to analyze the smoking cessation outcomes in both intention-to-treat and per-protocol analysis approaches. Results: Smokers receiving services from the Thai multidisciplinary smoking cessation clinics had CAR of 17.49 and 8.33% at 3 and 6 months, respectively. For those with cardiovascular disease (CVD) or cerebrovascular disease, CAR was found to be 26.36% at 3 months and 13.81% at 6 months. While participants with chronic obstructive pulmonary disease (COPD) had CAR ranging from 32.69% at 3 months to 17.31% at 6 months. Conclusion: The multidisciplinary team smoking cessation clinic was effective in assisting smokers in quitting smoking. The effectiveness of the clinic was more pronounced for smokers with CVD, cerebrovascular disease, or COPD. Findings from this study support a decision to include multidisciplinary smoking cessation clinics in the universal health care benefits package.

Expressional changes of carbamoyl phosphate synthetase and glutamine synthetase in the liver of rat with thioacetamide-induced cirrhosis.

BACKGROUND: In order to detoxify ammonia, mammalian livers use carbamoyl phosphate synthetase (CPS) and glutamine synthetase (GS) for conversion into respective non-toxic urea and glutamine. CPS is expressed in the periportal hepatocytes whereas GS is contained in the pericentral hepatocytes. OBJECTIVE: To examine the expressional changes of CPS and GS in the liver being induced to become cirrhotic by hepatotoxin thioacetamide (TAA). MATERIAL AND METHOD: Twenty-five male Wistar rats were divided into 5 groups of 5 animals each. Group 1 was for control. Groups 2 to 5 were treated with 200 mg/kg TAA intraperitoneally three times weekly for 1, 2, 3 and 4 months respectively. The immunohistochemical technique was employed in order to elucidate the expression of CPS and GS in each animal group. RESULTS: As centro-central fibrous bridging developed in the course of TAA treatment, expression of CPS declined dramatically and that of GS was no longer restricted to the pericentral hepatocytes. In month 4, CPS-positive hepatocytes were only found in some regenerative nodules, whereas GS expression became confined to the nodular periphery. Proper CPS staining required tissue fixation in a mixture of methanol, acetone and water (2:2:1 v/v) as opposed to 4% paraformaldehyde. CONCLUSION: In response to the hepatotoxin TAA, the liver attempts to regenerate by means of conserving persistent CPS-positive hepatocytes and rearranging GS-positive hepatocytes in response to vascular obstruction.

Overweight/Obesity and related factors among thai medical students.

This study was conducted to assess the prevalence of overweight/obesity and the related demographic data and health behaviors of Thai medical students. A cross-sectional study of 5441 medical students from all the 13 medical schools in Thailand was conducted in 2006 by means of a self-administered questionnaire. Demographic data, health behaviors, and self-reported body weight and height were recorded. The results revealed that Thai medical students have a lower prevalence of overweight/obesity than the general population of the same age group. The multiple logistic regression analysis showed that higher academic year was associated with being overweight or obesity in males, having improper dietary habits were associated with being overweight or obesity in both genders, whereas alcohol consumption was associated with being overweight in male only. Therefore, medical curricula should place an emphasis not only on knowledge but also on attitudes and behaviors for healthy lifestyles.

Predominant vascular dilatation with NOS expression in lung lower lobe of thioacetamide induced-cirrhotic rat.

BACKGROUND: About eighteen percent of cirrhotic patients come along with decreased systemic arterial oxygenation and expansion of pulmonary venous plexus which triggered by nitric oxide. The level of nitrate and iNOS significantly increase in the cirrhotic patients. However the localization of nNOS and iNOS in the lung tissue has not yet been clarified. OBJECTIVE: The present study, therefore, aimed to demonstrate the sites of expansion of pulmonary blood vessels and to localize nNOS and iNOS in the lung tissue of cirrhotic rat models induced by thioacetamide (TAA). MATERIAL AND METHOD: The rats were divided into 5 groups. The first group was the control. The other four groups were treated with 200 mg/kg body weight of TAA 3 times per week for 1, 2, 3, or 4 month(s), respectively. At the end of each month rats in each treated group were sacrificed. Lung histology and pulmonary NOS expression was studied by light microscope and immunohistochemical technique, respectively. RESULTS: It was found that diameter of blood vessels were highest increased in the right lower lobe of the 4-months TAA-treated group. In addition, iNOS and nNOS expression was localized at epithelium of respiratory tract, endothelium of pulmonary vessel and macrophage at this age. CONCLUSION: The present study demonstrated that the pulmonary blood vessels at the right lower lobe with cirrhotic background got enormous dilatation. iNOS and nNOS were immunostained at epithelium of respiratory tract, pulmonary endothelium and macrophages. Our observations suggested that enhanced NOS expression is important in the development of systemic hyperdynamic circulatory abnormalities in cirrhosis. As appearance of vasodilatation at right lower lobe of lung, it could, therefore, be evidence confirming that there was a real connection between inferior pulmonary vein and azygos vein at the embryonic period but obliterated later.

Effects of statins vs. non-statin lipid-lowering therapy on bone formation and bone mineral density biomarkers in patients with hyperlipidemia.

INTRODUCTION: The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, named statins, are well-established cholesterol-lowering drugs able to reduce cardiovascular risk in hypercholesterolemic patients. The possible effect of statin on bone tissue, so-called pleiotropic effects has received particular attention. Studies reported a positive effect of statin on bone tissue in both of animal and human study by enhancing the expression of the bone morphogenetic proteins (BMPs), in particular of BMP2, which in turn leads to osteoblast differentiation and bone formation including interfering with osteoclastic activity. In a systematic review, the lipophilic statin as simvastatin had positive effect to bone mineral density (BMD) better than the more hydrophilic statin such as atorvastatin and fluvastatin. This study was aimed to compare efficacy of medical therapy between HMG-CoA reductase inhibitor and non-HMG-CoA reductase inhibitor group to changing of bone mineral density and bone markers in the patients with hyperlipidemia. MATERIALS AND METHODS: A prospective randomized control trial study enrolled the 212 hyperlipidemia with osteopenia patients to study in year 2006-2008. All subjects were randomized to 2 groups between statin and non-statin group; the patients were screened by inclusion criteria and measured in bone mineral density (BMD), bone marker and blood chemistry. All data were analyzed by difference of changing in bone marker and BMD between statin and non-statin groups using paired t test. RESULTS: The present study showed 212 hyperlipidemia with osteopenia patients of which 106 patients in statin group had mean age (63.17+/-9.51 years) and the same number of patients in non-statin group had mean age (60.96+/-8.9 years). All subjects were 63 patients in male and 149 patients in female. Difference of bone formation marker and BMD between after and before was significantly higher than in statin group and the difference of bone resorption marker was also significantly lower than in statin group. CONCLUSION: The lipophilic statin as moderate to high dose of simvastatin had beneficial positive effect to increasing BMD and could be additive use for prevention of bone loss in hyperlipidemia patients.

Laparoscopic biliary bypass with an autologous tubed gastric flap: a pilot study.

Although biliary bypass technique which used jejunum as a conduit is a common procedure in open technique of hepatobiliary tract surgery, its complicated technique made it is not feasible for laparoscopic surgery. Before 1960, stomach was used vastly for biliary drainage but late stricture which resulted from too much tension along suture line made it not much acceptable. The authors report surgical technique of laparoscopic gastric tube flap for biliary bypass in order to made it practicable for laparoscopic surgery.

Temperature dependency of bidirectional flux in the rat intestine subjected to graded ischemia.

This study examined the effect of temperature and ischemia on permeation of fluorescently-labeled dextran (M.W. = 4 kDa; FD4) across rat intestinal mucosa. Permeability was evaluated ex vivo using an everted gut sac technique in both the mucosal-to-serosal (M-->S) and serosal-to-mucosal (S-->M) directions. At baseline (B), 30-min of ischemia (I-30) and 60-min of ischemia (I-60), intestinal segments were prepared and incubated at 37 degrees C, 15 degrees C and 4 degrees C for 30 min. Clearance (nl/min/cm2) was calculated based on the accumulated amount of FD4 at 30 min. Both M-->S and S-->M fluxes increased with increasing temperature at B, I-30 and I-60. Ischemic gut (I-30 and I-60) had about a three-fold higher (M-->S)/(S-->M) flux ratio than that of normal gut (p < 0.001). At 4 degrees C, neither M-->S nor S-->M flux was different between B and I-30, but both M-->S and S-->M fluxes significantly increased at I-60, suggesting an increase in permeation via a passive mechanism. Increased bidirectional fluxes at 37 degrees C were obtained in the I-30 and I-60 gut sacs when compared to B. We conclude that FD4 is actively transported across the intestinal mucosa in the S-->M direction and that ischemic injury increases passive diffusion of the probe across the gut wall.

Evaluation of dermal irritancy potential of Carboxymethyl-chitosan hydrogel and poly-(acrylic acid) chitin hydrogel.

OBJECTIVE: The wound dressing synthesized from carboxymethylchitosan hydrogel (CM) and chitin-(polyacrylic acid) hydrogel (PAA) were examined for their dermal irritation potential response using the Draize test. MATERIAL AND METHOD: Eighteen male Sprague-Dawley rats were divided into three groups (6 rats/each). Rats in group 1 were designed as control, group 2 were treated with CM, and group 3 were treated with PAA. The test materials diameter 1 x 1 cm were topically applied on the skin in group 2 and 3. Two skin sites (1 x 1 cm in size) were located at the back. One site was intact and the other was abraded in such a way the stratum corneum had no bleeding. RESULT: After 24 and 72 hours of wrappings, the materials were removed and the test sites were evaluated in terms of erythema and edema using adopted Draize scoring system. At the end of the experiment, all rats were anesthesized with intravenous thiopental sodium. Blood samples from descending aorta were collected for liver and kidney function test and all organs were weighed. The results of this experiment showed 1) no irritation of both materials in this animal model; 2) no material-related induced liver and kidney dysfunction and 3) organ weights had no significant difference between the groups. CONCLUSION: Both CM and PAA should be considered safe to use in the purpose of wound dressing in further clinical trials.

Longevity of Thai physicians: phase 2 and policy implications.

This is Phase 2 of the authors study on long-lived Thai physicians. After obtaining quantitative data from Phase 1, the authors approached 11 male and 5 female physicians whose ages were older than general population's life expectancy. The authors conducted an in-depth interview using semi-structured questions asking about their life, work, lifestyle, and relevant factors. Then the authors synthesized the factors influencing longevity. The authors found that they are genetic, financial stability/security, trying to be disease-free by increasing positive lifestyle (such as exercise) and decrease negative lifestyle (such as drug addict, alcohol consumption), mind-set to be non-attachment (either doing nothing or busy doing everything), and being mentally ready to die. The authors also proposed policy implications for Thai physicians and people accordingly.

Thai physicians health survey.

Physicians often conduct research on other occupations' health or general populations' health, but their health has hardly been studied systematically. The authors conducted a cross-sectional descriptive survey on 440 physicians systematically selected from their medical license numbers. The response rate was 86.4% (380 out of 440). Two-hundred and twenty-nine were male, and 151 were female. Their average age was 40.8 years (range: 22-74). Most of them were Buddhists (93.9%), specialists (64.2%), married only once and still lived with their spouses (59.5%), and concurrently practiced medicine (95.5%). Their overall satisfaction as physicians was 60.2% high, and 37.2% moderate. Their average sleep time was 6-8 hours per night for 58.9%. Most had eye problems (74.9%) and most were refractive errors such as myopia. Most (63.8%) of them did not have any prevalent diseases. Whereas those who had diseases had (in order) allergy, hypertension, asthma, diabetes, and cancer. Their current illnesses included respiratory tract infection. Most physicians did not smoke (94.2%) nor drink alcohol (70.5%). Most of them were not vegetarians (60.4%), did not eat fast food (99.2%). Interestingly, 41.4% of them were accounted for spending less than twice per week for exercise. As expected, 23.7% of them were exposed to blood, 14.5% to respiratory tract secretion, and 13.7% to pus/secretion from wounds. This study serves as a basis for health promotion approach to medical community and does create awareness of health among Thai physicians.

Thai physicians' career satisfaction.

The purposes of this cross-sectional study were to collect data regarding satisfaction and influencing factors related to satisfaction of Thai Physicians. The survey was conducted during October 2002 to March 2003. Study subjects were 440 physicians obtained by systematic random sampling. They were asked to reply posted questionnaire and telephone interviewed later if they did not reply the mailed questionnaire. The authors could obtain data from 380 out of 440 cases (86.3%), 60.3% were male and 39.7% were female. Their average age was 43.9 and 37.7 years, respectively, with an overall average of 40.9 years. The level of career satisfaction of Thai Physicians was high (60.2%), moderate (37.2%) and low (2.6%). Conclusively the factors which influenced or predicted satisfaction of Thai physicians were age, exercise and accident. The author make some recommendations for improving Thai physicians' satisfaction.

Life expectancy of Thai physicians during 1998-2002.

Previous report suggested early age at death of Thai physicians; the estimate however was not a comparable measurement with general Thai population. This information created a concern on the health status of Thai population. This study was therefore aimed to calculate life expectancy of Thai physicians and to compare with Thai population. Information on year of birth of all registered physicians and year of death of physicians who died during 1998-2002 was retrieved from the database of the Thai Medical Council and the Centre for Continuing Medical Education of Thailand. Age-specific mortality rates were computed for ages of 23-24, 25-29, and then 5-year intervals until 70 years or more. These age-specific mortality rates were used for calculation of life expectancy by using the method of abridged life table. During the year 1998-2002, there were 655 deaths among 25,501 Thai physicians. According to life table calculation, life expectancy at age 23 for Thai physicians was 63.5 years or they could live until age of 86.5 years when they started their career and those figures for Thai general population were 53.2 and 76.2 respectively. The differences between these two populations were declined in older age groups. Increased life expectancy among physicians compared to general population was also reported in other countries. A longer life span of physicians might be a result of higher socioeconomic status and low prevalence of health risk behavior.

Survey of mental health status of Thai physicians.

This survey was aimed at obtaining a screening survey on mental health status of Thai physicians. We systematically sampled to obtain 440 Thai physicians from the directory of Thai Center for Continuing Medical Education (CCME). Then, we obtained their mental health status by mailing a questionnaire containing Thai GHQ-28 and asking them to reply, later we obtained through telephone interview. The response rate was 86.3 percent, and 60.3 percent of them were male. The result revealed that 15 male and 13 female physicians had abnormal mental health status. The overall prevalence rate of abnormal mental health status was 7.4 percent. We also found a significant negative association between mental health status and career satisfaction and the use of sedatives in the past 6 months. This study pointed out that mental health of some Thai physicians was to be concerned. These problems, along with their physical health problems, should be tackled systematically and preventatively in order to have the majority of Thai physicians in good health and able to serve the population more effectively.

Risk factors for suicide among Thai physicians.

OBJECTIVES: To investigate the risk factors for suicide in Thai physicians. METHOD: The study focused on 18 doctors who had committed suicide before January 2002, identified by death certificates and the reported data from Thai Medical Council. Consensus case reports were assembled by using the psychological autopsy method. Study methods included semi-structured and in-depth interviews of next of kin and interviews of classmates, colleagues and medical or mental health services workers who had treated the suicide victims. RESULTS: The sample consisted of 18 subjects (17 males, one female). The age range was 30-49 years old. Most victims were specialists (11 out of 18; 3 gynecologists, 2 psychiatrists, 2 pediatricians, 2 surgeons and 1 internist, 1 radiologist). The methods of suicide were 6 hanging, 5 gun shots, 5 intravenous injections, 1 jumping and 1 drug over-dose. Psychiatric disorders were found in 11 out of 18 cases, and depressive disorder was the most common disorder. Interpersonal conflict and/or loss were the most common factors leading to suicide (6 out of 18), the second factor was psychiatric illness and the third factor was work problems. CONCLUSION: In assessing suicidal risk, a history of interpersonal conflicts and loss and the presence of co-morbid psychiatric disorders are particularly important. The important strategies for suicide prevention in Thai physicians are early detection and proper management of psychiatric illness especially depressive disorder and recognition the significance of family support.

Longevity of Thai physicians.

The objectives of this study were to explore characteristics of the long-lived Thai physicians. We sent 983 posted questionnaires to 840 male and 143 female physicians. We obtained 327 of them back after 2 rounds of mailing, yielding a response rate of 33.3 percents. The response rate of male physicians was 32.4 percents and that of female physicians was 38.5 percents. Their ages were between 68-93 years (75.1 +/- 4.86 years on average). The majority were married, implying that their spouses were also long-lived. Around half of them still did some clinical work, one-fourth did some charity work, one-fourth did various voluntary works, one-fifth did some business, one-fifth did some academic work, and some did more than one type of work. Most long-lived physicians were not obese, with BMI of 16.53-34.16 (average 23.97 +/- 2.80). Only 8 had BMI higher than 30. BMIs were not different between male and female physicians. However, four-fifths of them had diseases that required treatment, and some of them had more than one disease. The five most frequent diseases were hypertension, diabetes, ischemic heart disease, dyslipidemia, and benign prostate hypertrophy, respectively. Most long-lived physicians did exercise (87.8%), and some did more than one method. The most frequent one was walking (52.3%). Most did not drink alcohol or drank occasionally, only 9.0% drank regularly. Most of them slept 3-9 hours per night (average 6.75 +/- 1.06). Most (78.3%) took some medication regularly; of most were medicine for their diseases. Most did not eat macrobiotic food, vegetarian food, or fast food regularly. Most long-lived physicians practiced some religious activities by praying, paying respect to Buddha, giving food to monks, practicing meditation, and listening to monks' teaching. They also used Buddhist practice and guidelines for their daily living and work, and also recommended these to their younger colleagues. Their recreational activities were playing musical instruments (15%), singing (27%), doing hobbies (64.0%), and others (51.8%). Most did not reply on question whether they achieved their self-actualization target of their lives, this might result from the fact that this was rather an abstract question. Our first part study revealed some characteristics of long-lived Thai physicians that seem to be in agreement with other studies indicating that physicians compared favorably with the general population in mortality from physical illness. This may result from several factors: the medical student selective process leading to "healthy worker effect", knowledge in medicine, access to care, and their healthy behaviors (such as nutrition, exercise, religious activities which help improve their spiritual well-being).