Sivaraj Raman

Sodium-glucose co-transporter-2 (SGLT2) inhibitors such as Empagliflozin, are increasingly recommended as part of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) in many developed nations. This recommendation is based on robust clinical evidence showing that adding Empagliflozin to GDMT improves heart failure symptoms, clinical outcomes, functional status, and overall quality of life. In Malaysia, where healthcare is predominantly public and heavily subsidized, the introduction of new treatments can significantly impact costs, requiring detailed economic assessments. This study evaluates the budget impact of incorporating Empagliflozin into GDMT for HFrEF from the perspective of the public healthcare system. A five-year budget impact model was developed, integrating local data such as population, drug use, costs, clinical outcomes, and healthcare expenses. In the current scenario (GDMT alone), the projected five-year expenditure is MYR 6.12 billion (USD 3.92 billion). With Empagliflozin, the total cost rises by 0.71% to MYR 6.16 billion (USD 3.95 billion), driven by drug acquisition costs of MYR 160.12 million (USD 102.64 million) and adverse event costs of MYR 211,543 (USD 135,604). However, these costs are offset by savings from reduced HF hospitalizations, fewer cardiovascular deaths, and improved renal outcomes. Sensitivity analysis identified hospitalization costs, the price of Empagliflozin, and cardiovascular deaths in diabetic patients as key factors influencing the budget impact. Policymakers can improve the affordability of Empagliflozin through strategies like price negotiations, cost-sharing, and focusing on high-risk groups to optimize healthcare expenditure while ensuring effective treatment access.

Cancer patients often grapple with substantial out-of-pocket (OOP) expenses and productivity loss, with the ramifications being particularly crucial for lower-income households. This study aims to estimate OOP costs incurred by cancer patients, assess their productivity loss, and analyse the financial coping mechanisms employed by individuals within the lower-income bracket. The study employed face-to-face interviews among cancer patients aged 40 years and above, currently undergoing treatment, and belonging to the lower-income group. Participants were recruited from six public cancer referral hospitals. OOP expenses, encompassing medical and non-medical costs, along with productivity loss, were measured. A generalized linear model was applied to identify potential OOP determinants. Additionally, the coping mechanisms employed by individuals to finance their cancer OOP expenses were also determined. Among the 430 participants recruited, predominantly female (63.5%), and aged 60 or older (53.9%). The annual mean total cancer costs per patient were US$ 2,398.28 (±2,168.74), including 15% for medical costs US$ 350.95 (±560.24), 34% for non-medical costs US$820.24 (±818.24), and 51% for productivity loss costs US$1,227.09 (±1,809.09). Transportation, nutritional supplements, outpatient treatment, and medical supplies were notable cost contributors to total OOP expenditures. Ethnicity (β = 1.44; 95%CI = 1.15–1.79), household income (β = 1.40; 95%CI = 1.10–1.78), annual outpatient visits (β = 1.00; 95%CI = 1.00–1.01), age (β = 0.74; 95%CI = 0.56–0.98), and employment status (β = 0.54; 95%CI = 0.72–1.34) were identified as significant predictors of OOP costs among cancer patients. Notably, 91% of participants relied on household salaries and savings, while 15% resorted to interest-free borrowing, 11% sold possessions, and 0.5% borrowed with interest to finance their expenses. This study offers crucial insights into the economic impact of cancer on individuals and their families, providing policymakers with valuable information to tackle challenges faced in their journey. Despite substantial public healthcare subsidies, the study revealed that cancer costs can remain a potential barrier to accessing essential treatment. Therefore, there is a need for reinforced system-level infrastructure to facilitate targeted financial navigation services.

A lack of guidance on economic evaluations for oral cancer screening programs forms a challenge for policymakers and researchers to fill the knowledge gap on their cost-effectiveness. This systematic review thus aims to compare the outcomes and design of such evaluations. A search for economic evaluations of oral cancer screening was performed on Medline, CINAHL, Cochrane, PubMed, health technology assessment databases, and EBSCO Open Dissertations. The quality of studies was appraised using QHES and the Philips Checklist. Data abstraction was based on reported outcomes and study design characteristics. Of the 362 studies identified, 28 were evaluated for eligibility. The final six studies reviewed consisted of modeling approaches (n = 4), a randomized controlled trial (n = 1), and a retrospective observational study (n = 1). Screening initiatives were mostly shown to be cost-effective compared to non-screening. However, inter-study comparisons remained ambiguous due to large variations. The observational and randomized controlled trials provided considerably accurate evidence of implementation costs and outcomes. Modeling approaches, conversely, appeared more feasible for the estimation of long-term consequences and the exploration of strategy options. The current evidence of the cost-effectiveness of oral cancer screening remains heterogeneous and inadequate to support its institutionalization. Nevertheless, evaluations incorporating modeling methods may provide a practical and robust solution.

Background: Despite emergency ambulance services playing a pivotal role in accessibility to life-saving treatments in Malaysia, there are still numerous gaps in knowledge in terms of their utilization and cost. This leads to current policies on procurement, maintenance, and allocation being predicated on historical evidence and expert opinions. This study thus aims to analyse the cost and utilization of ambulance services in selected public health facilities in Malaysia. Methods: A cross-sectional study was employed involving 239 ambulances from selected hospitals and clinics. Ambulance service utilization was based on the number of trips, distance and duration of travel obtained from travel logbooks. A mixed top-down and activity-based costing approach was used to estimate the monthly cost of ambulance services. This constituted personnel, maintenance, fuel, overhead, consumables, ambulance, and medical equipment costs. The utilization and costs of ambulance services were further compared between settings and geographical locations. Results: The average total cost of ambulance services was MYR 11,410.44 (US$ 2,756.14) for hospitals and MYR 9,574.39 (US$ 2,312.65) for clinics, albeit not significantly different. Personnel cost was found to be the main contributor to the total cost, at around 44% and 42% in hospitals and clinics, respectively. There was however a significant difference in the total cost in terms of the type and age of ambulances, in addition to their location. In terms of service utilization, the median number of trips and duration of ambulance usage was significantly higher in clinics (31.88 trips and 58.58 hours) compared to hospitals (16.25 trips and 39.25 hours). Conclusions: The total cost of ambulance services was higher in hospitals compared to clinics, while its utilization showed a converse trend. The current findings evidence that despite the ambulance services being all under the MOH, their operating process and utilization reflected an inherent difference by setting.

This study aims to evaluate the time-to-treatment of oral cancer and potentially malignant oral disorders (PMOD) in a Malaysian public healthcare setting while exploring its contributing factors. It consists of (1) a cross-sectional patient survey to quantify time to seek care and barriers faced, and (2) a retrospective medical record abstraction to determine treatment and management intervals. Time intervals were aggregated and analyzed by their primary contributor—patient, professional, or healthcare system. The average total time-to-treatment of the 104 patients investigated was 167 days (SD = 158). This was predominantly contributed by the patient interval of 120 days (SD = 152). In total, 67.0% of patients delayed their visit to primary healthcare centers because they assumed the lesions were not dangerous or of concern. Additionally, there was a significant difference between patients ‘facing’ and ‘not facing’ difficulties to seek care, at 157 vs. 103 days (p = 0.028). System and professional delays were comparably shorter, at 33 days (SD = 20) and 10 days (SD = 15) respectively. Both demonstrated a significant difference between oral cancer and PMOD, at 43 vs. 29 days (p < 0.001) and 5 vs. 17 days (p < 0.001). The findings reiterate the need to reform current initiatives to better promote early lesion recognition by patients and implement strategies for the elimination of their access barriers.

Oral cancer has been recognized as a significant challenge to healthcare. In Malaysia, numerous patients frequently present with later stages of cancers to the highly subsidized public healthcare facilities. Such a trend contributes to a substantial social and economic burden. This study aims to determine the cost of treating oral potentially malignant disorders (OPMD) and oral cancer from a public healthcare provider’s perspective. Medical records from two tertiary public hospitals were systematically abstracted to identify events and resources consumed retrospectively from August 2019 to January 2020. The cost accrued was used to estimate annual initial and maintenance costs via two different methods- inverse probability weighting (IPW) and unweighted average. A total of 86 OPMD and 148 oral cancer cases were included. The initial phase mean unadjusted cost was USD 2,861 (SD = 2,548) in OPMD and USD 38,762 (SD = 12,770) for the treatment of cancer. Further annual estimate of initial phase cost based on IPW method for OPMD, early and late-stage cancer was USD 3,561 (SD = 4,154), USD 32,530 (SD = 12,658) and USD 44,304 (SD = 16,240) respectively. Overall cost of late-stage cancer was significantly higher than early-stage by USD 11,740; 95% CI [6,853 to 16,695]; p< 0.001. Higher surgical care and personnel cost predominantly contributed to the larger expenditure. In contrast, no significant difference was identified between both cancer stages in the maintenance phase, USD 700; 95% CI [-1,142 to 2,541]; p = 0.457. A crude comparison of IPW estimate with unweighted average displayed a significant difference in the initial phase, with the latter being continuously higher across all groups. IPW method was shown to be able to use data more efficiently by adjusting cost according to survival and follow-up. While cost is not a primary consideration in treatment recommendations, our analysis demonstrates the potential economic benefit of investing in preventive medicine and early detection.