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Fulltext Assessing the cost effectiveness of an anticoagulation clinic in comparison with the usual medical clinic In Kuala Lumpur Hospital [Abstract]

Thanimalai S, Shafie AA, Ahmad HM, Sinnadurai J

Value Health, 2014 Nov;17(7):A487.
PMID: 27201439 DOI: 10.1016/j.jval.2014.08.1428

Objectives: Systematic anticoagulation management clinic is now recommended to manage warfarinized atrial fibrillation (AF) patient. In Malaysia, the service is recently introduced as pharmacist managed Warfarin Medication Therapy Adherence Clinic (WMTAC). The objective of the present study was to assess the cost effectiveness of anticoagulation clinic in comparison with usual medical in Kuala Lumpur Hospital.
Methods: A Markov model built using the provider perspective and 20 year time horizon was used to assess the cost effectiveness. The base case analysis assumed a cohort of patients with AF 57 years of age with comorbid illnesses. Data sources include a 6 month retrospective cohort analysis of the effectiveness of the clinics, the cost of drugs, cost of personnel and space of the clinics, cost of monitoring and cost of adverse events were obtained from the local source and publications. The transition probabilities of these clinics outcomes were obtained from a literature search. Future costs were discounted by 3% to convert to present values. All costs were in Ringgit Malaysia (RM) based on year 2012.
Results: The results of a 20-year period model showed that UMC was dominated by the WMTAC in the same time period. The mean cost of the WMTAC was RM 5864 whereas the UMC cost was RM 6550. The sensitivity analysis showed that clinic treatment costs and effectiveness influenced the cost-effectiveness. If the cost of WMTAC was increased by 50% of the current cost, the WMTAC would not be a dominant intervention. WMTAC was also cost effective for a willingness to pay of RM32000.
Conclusions: The anticoagulation management service appears to cost less and provide greater effectiveness than usual care. In conclusion, the Markov model suggests that from the provider perspective the anticoagulation clinic is a more cost effective option than the usual medical clinic in Kuala Lumpur Hospital.
Study site: Medication Therapy Adherence Clinic, Hospital Kuala Lumpur, Malaysia
Comparing effectiveness of two anticoagulation management models in a Malaysian tertiary hospital

Thanimalai S, Shafie AA, Hassali MA, Sinnadurai J

Int J Clin Pharm, 2013 Oct;35(5):736-43.
PMID: 23715759 DOI: 10.1007/s11096-013-9796-6

BACKGROUNDS: Limited evidence is available regarding pharmacist managed anticoagulation clinic in the Southeast Asian region where there is marked difference in terms of care model, genetic composition and patient demographics.

OBJECTIVES: This study aimed at comparing the anticoagulation clinic managed by the pharmacist with physician advisory and the usual medical care provided in Kuala Lumpur Hospital (KLH) in terms of anticoagulation control and adverse outcomes.

SETTING: A 2,302 bedded government tertiary referral hospital in Malaysia.

METHODS: A 6-month retrospective cohort study of the effectiveness of two models of anticoagulation care, the pharmacist managed anticoagulation clinic which is known as warfarin medication therapy adherence clinic (WMTAC) and usual medical clinic (UMC) in KLH was conducted, where a random number generator was used to recruit patients. The UMC patients received standard medical care where they are managed by rotational medical officers in the physicians' clinic. As for the WMTAC with physician advisory, the pharmacist will counsel and review the patients internationalised normalization ratio at each clinic visit and also adjust the patients' warfarin dose accordingly. Patients are referred to physicians if immediate attention is required.

MAIN OUTCOME MEASURE: The main therapeutic outcome is time in therapeutic range (TTR) both actual and expanded TTR and thromboembolic and bleeding complications.

RESULTS: Each of the WMTAC and usual medical care recruited 92 patients, which totals to 184 patients. The patient demographics in terms of age, race and indication of treatment were comparable. At the end of the 6 months follow-up, patients in the WMTAC group had significantly higher actual-TTR (65.1 vs. 48.3 %; p < 0.05) compared to those in usual medical care group. Rates of admission were 6.5 versus 28.2 events per 100 person-years for the WMTAC and UMC groups, respectively. Though the bleeding incidences were not significantly different, it was reduced.

CONCLUSIONS: These findings will impact local warfarin patient management services and policies because there was no available evidence supporting the role of pharmacists in the management of warfarin patients prior to this study.
Cost-effectiveness of warfarin medication therapy adherence clinic versus usual medical clinic at Kuala Lumpur Hospital

Thanimalai S, Shafie AA, Ahmad Hassali MA, Sinnadurai J

Value Health Reg Issues, 2018 May;15:34-41.
PMID: 29474176 DOI: 10.1016/j.vhri.2017.05.006

BACKGROUND: Systematic anticoagulation management clinic is recommended to manage patients on chronic warfarin therapy. In Malaysia, the service was introduced as warfarin medication therapy adherence clinic (WMTAC), which is managed by pharmacists with a physician advisory.
OBJECTIVES: To assess the cost-effectiveness of WMTAC in comparison with usual medical clinic (UMC), which is managed by medical officers in Kuala Lumpur Hospital, a tertiary referral hospital in Malaysia.
METHODS: Data from a 6-month retrospective cohort study comparing the two clinics and the mean percentages of time in the therapeutic range for the patients were used to estimate the cost-effectiveness. The mean clinic costs were estimated using the time-motion study. A Markov model with a 6-monthly cycle was used to simulate lifetime cost-effectiveness from the perspective of the health care service provider. The base-case analysis assumed a cohort of patients with atrial fibrillation, 57 years of age with comorbid illnesses. The transition probabilities of these clinic outcomes were obtained from a literature search. Future costs and effectiveness were discounted by 3% to convert to present values. All costs were in Malaysian ringgit standardized for the year 2007.
RESULTS: The mean 6-month treatment cost was lower for the WMTAC, which was significantly lower (P < 0.001). The UMC was found to be dominated by the WMTAC for both intermediate and lifetime analyses. The sensitivity analysis showed that clinic consultation costs had a major impact on the cost-effectiveness analysis.
CONCLUSIONS: WMTAC is a more cost-effective option than UMC in Kuala Lumpur Hospital.
Study site: Medical clinic, Hospital Kuala Lumpur, Malaysia
Fulltext Severity and Hospitalization Cost Related to Warfarin-Related Adverse Events in a Tertiary Malaysian Hospital

George D, Wong CA, Thanimalai S, Tan HS

Hosp Pharm, 2022 Oct;57(5):633-638.
PMID: 36081534 DOI: 10.1177/00185787211070182

Introduction: Oral anticoagulant is essential for the treatment and prevention of thromboembolism. Warfarin is an effective oral anticoagulant in prevention and treatment of thromboembolism. However, warfarin is frequently associated with adverse event (AE) requiring hospitalization. Method: We performed a retrospective cohort study of all patients admitted to a large tertiary public hospital for warfarin-related AEs. Patients were grouped based on bleeding severity and the direct medical cost was also calculated. Results: During the 4 years study period, a total of 224 patients were admitted for warfarin-related AEs. Mean age of patients admitted was 65.1 years (standard deviation [SD] = 11.5). More than half, 59.6%, of them were on warfarin for prevention of stroke in atrial fibrillation or atrial flutter. Major bleeding occurred among 50.9% of the patients with gastrointestinal bleed, 34 (29.8%), as the common site of bleed. Patients with major bleed had longer median hospital stay of 4 days (interquartile range [IQR] = 5) compared to 3 (IQR = 3) days in non-major bleed. There were 17 (14.9%) death among the major bleeders. Mean medical cost for managing warfarin-related AEs was USD 708.08. Conclusion: The admitted patients were equally distributed in terms of bleeding severity. Medical cost incurred for managing warfarin-related AEs increased with the severity of bleeding.
Fulltext Estimating the utility value of hypoglycaemia according to severity and frequency using the visual analogue scale (VAS) and time trade-off (TTO) survey

Shafie AA, Ng CH, Thanimalai S, Haron N, Manocha AB

J Diabetes Metab Disord, 2018 Dec;17(2):269-275.
PMID: 30918862 DOI: 10.1007/s40200-018-0369-z

Objectives: The primary objective of this study was to estimate the health utility values for hypoglycaemia events according to their severity and frequency. The secondary objective was to compare the health utilities between those with Type 2 Diabetes Mellitus and the general population.
Method: The health utilities of hypoglycaemia event were measured using Visual Analogue Scale (VAS) and Time Trade-Off (TTO) methods among conveniently sampled consenting adults (>18 years and literate in either English or Malay language), which were then divided into two groups: those in the general population (GP) and those with Type 2 Diabetes Mellitus (T2DM). Each respondent was required to value 13 different health states, including frequencies of daytime hypoglycaemia and nocturnal hypoglycaemia, each depending on its severity (non-severe or severe).
Results: 256 respondents from the GP and 99 respondents with T2DM completed the survey. The T2DM group gave higher VAS-values compared to the GP group. The highest mean VAS-utility value for non-severe nocturnal hypoglycaemia occurring once monthly was 0.543 (SD 0.161), and for severe daytime hypoglycaemia occurring once quarterly was 0.293 (SD 0.162) which was the lowest utility value compared to other health states. However, non-severe nocturnal hypoglycaemia occurring once quarterly was 0.537 (SD 0.284) and has the highest TTO-utility value. Severe nocturnal hypoglycaemia occurring once quarterly has the lowest utility value which was -0.104 (SD 0.380). Daytime hypoglycaemia has lower utility value compared to nocturnal hypoglycaemia. Severe hypoglycaemia has a greater disutility compared with the non-severe hypoglycaemia in both studied groups.
Conclusion: The findings show that as a health utility, hypoglycaemia has a substantial impact on utility with severe hypoglycaemia having a greater negative impact compared to non-severe events across the board. This highlights the importance of preventing development of severe hypoglycaemia in patients with Type 2 Diabetes Mellitus at any time of the day.