Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

"Journal of clinical and diagnostic research is a welcome change in publishing practices. It aims to reach out to the grass-root level researchers who do not lack in experience, clinical material and ideas, but lack in their knowledge in English language and statistics. The journal achieves it's aim by supporting in these exact domains.
It also gives due credit to all research designs like descriptive and qualitative studies while many journals ignore these important study designs. The rigorous review process does not allow any compromise in quality
It is indexed in many indexing agencies and the articles are available under creative commons licence free of cost
The frequency of publication supports many aspiring authors from India and other countries.
It's wide scope welcomes articles across various specialities in medicine. In an era when there is an unscientific insistence on speciality specific research by regulatory bodies in medical education, JCDR supports collaborative research across specialities. I wish the publisher all the best in his future endeavors."



Dr. Archana Dambal
Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2010 | Month : December | Volume : 4 | Issue : 6 | Page : 3371 - 3377

The Impact of Poorly Controlled Hypertension on Ambulatory Care Resources in Malaysia

QAIS AEFAN , M I M IBRAHIM,TARIQ A RAZAK ,AZIZI AYUB

Department of Pharmacy Practice, Kulliyyah of Pharmacy, IIUM, Jalan Sultan Ahmed Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang, Malaysia

Correspondence Address :
Qais Aefan, M.Pharm (Clinical)**
Lecturer and Doctoral Research Fellow, Department of Pharmacy Practice, Kulliyyah of Pharmacy, IIUM, Jalan Sultan Ahmed Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang, Malaysia
qefan@yahoo.com, Telephone: +60142917992, Fax: +6095716775

Abstract

Aim: Since many Malaysians with hypertension have poor control rates of blood pressure, this study wasconducted to determine the impact of uncontrolled hypertension on the utilization of ambulatory care resources.
Setting: The study took place at the Jaya Gading Polyclinic in Kuantan city, Pahang, Malaysia.

Methods: This was a1year follow-up of 600 hypertensive patients who were classified into groups, based on average blood pressure. The monthly direct and indirect costs and the differences in costs were determined.
Main outcome measure: Data analysis using the Mann-Whitney test was performed to compare the direct costswhich were associated with controlled and uncontrolled blood pressure.

Results: The direct costs were significantly higher in the uncontrolled blood pressure groups as compared to the controlled blood pressure groups. Medication costs represented the major portion of the total direct costs in both the controlled and the uncontrolled blood pressure groups.

Conclusion: Poor control of uncomplicated hypertension is associated with the higher utilization of the ambulatory care resources in Malaysia. Aggressive strategies are needed to control hypertension and to reduce the utilization of the ambulatory care resources.

Keywords

Hypertension control, cost, ambulatory care, Malaysia

How to cite this article :

QAIS AEFAN , M I M IBRAHIM,TARIQ A RAZAK ,AZIZI AYUB . THE IMPACT OF POORLY CONTROLLED HYPERTENSION ON AMBULATORY CARE RESOURCES IN MALAYSIA. Journal of Clinical and Diagnostic Research [serial online] 2010 December [cited: 2019 Aug 22 ]; 4:3371-3377. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2010&month=December&volume=4&issue=6&page=3371-3377&id=1042

Introduction
Adequate control of blood pressure reduces cardiovascular morbidity, mortality and in general, health care costs. In the U.S., inadequate blood pressure control resulted in 39,702 cardiovascular events, 8,374 cardiovascular disease deaths and a direct medical cost of US$ 964 million in 2002 (1). Patients with uncontrolled blood pressure are associated with the higher utilization of health care resources as compared to patients with controlled blood pressure (2),(3),(4),(5),(6). Patients with higher blood pressure are also associated with shorter time to the next physician visit, higher number of visits and higher medication costs (7),(8).

Hypertension is highly prevalent and severe in Malaysia, its care is unsatisfactory and its detection and treatment are inadequate. The most recent Malaysian study on the prevalence of hypertension showed that hypertension prevalence is 27.8% and that it increases with age in both genders and in all the ethnic groups. Malaysians with hypertension have low awareness about their hypertension, low treatment and the poor control rates of their blood pressure. Only 34.6% of the study subjects were aware of their hypertension, 32.4% were taking antihypertensive drugs and of these, only 26.6% had controlled blood pressure. Overall, 8.6% of the hypertensives had their blood pressure controlled (9). Researchers believe that patients with poorly controlled hypertension in Malaysia create an economic burden on the national health care budgets and utilize higher ambulatory care resources as compared to patients with controlled hypertension. To the best of our knowledge, the impact of poorly controlled hypertension on the ambulatory care resources in Malaysia, has not been estimated. In this study, we examined the difference between controlled and poorly controlled hypertension in the 3 stages with regards to ambulatory care cost. This study was conducted to estimate the impact of poorly controlled blood pressure in each stage of uncomplicated hypertension on the utilization of ambulatory care services in Malaysia.

Material and Methods

Study design
Data analyses of the 1-year follow-up from 1st January 2007 to 31st December 2007 of hypertensive patients was conducted to determine the direct and indirect costs which were attributable to uncomplicated hypertension among controlled and poorly controlled hypertensive patients. Using the history data of the patients and the blood pressure levels, it was possible to classify all patients into 3 stages of hypertension, based on their average systolic and diastolic blood pressure (i.e., prehypertension, stage 1 and stage 2) according to the JNC 7 classification (10). After following up the three groups, the patients in each group were classified as having controlled or poorly controlled blood pressure at the end of the prospective year of the study. Controlled blood pressure was defined as a blood pressure of < 140/90 mmHg. Poorly controlled blood pressure was defined as a blood pressure of ≥ 140/90 mmHg (10). The look-back time horizon was 2 years. The index date was defined as the date on which a patient received his or her first antihypertensive prescription on or after January 1st, 2005. Patients who signed the informed consent sheet (N=600) were included in the study, based on the following criteria: (a) age was 18 years or above as in January 2007, (b) the presence of a diagnosis or a history of uncomplicated hypertension, (c) there was at least one prescription of antihypertensive drugs, (d) the absence of co-morbidities and (e) the informed consent was signed.

Data Collection
The data which were collected in this study were the data which were related to the management of hypertension. The data collected by using the case record form and the standard questionnaire were validated by a numberof experts in the research field. An informed consent form was prepared in English, Bahasa Malaysia, Mandarin and Indian languages in order to allow the participants to make an informed decision on whether to participate in the study or not. In addition to the main researcher, two senior staff-nurses helped in collecting the data. The staff-nurses were instructed about the purpose and the duration of the study and the data needed for the study and were trained on how to collect the required data. The data collected was stored as binary numbers, normal numbers and dates. Some data were coded when necessary (e.g. drugs names, tests names, etc).

During the first visit, the study subjects were interviewed to collect data regarding their age, sex, and race. Their blood pressure was measured and the average reading was recorded by the two staff-nurses by using a standard mercury sphygmomanometer on the right arm of each participant, in the sitting position, after at least 5-minutes of rest. Three blood pressure readings were taken from the patients during each visit and were averaged to yield one measurement for that visit. All blood pressure measurements taken during the study period were averaged for each patient to yield a mean value for the whole period. The data on new prescriptions of antihypertensive medications, the drug names, dosages, dosing intervals and diagnostic and laboratory tests were also collected. In addition, the main researcher collected similar retrospective data from the patients’ medical files. Only visits related to hypertension were studied and the society’s perspective was used in this study.

Cost Estimation
The monthly average direct costs were divided into four categories: antihypertensive medications, laboratory and diagnostic tests and the costs of the health professionals and transportations. The means of the costs were calculated according to the blood pressure control status (i.e., controlled and uncontrolled). The utilization rate of the direct costs was calculated as the number of the direct cost component (e.g., drug, laboratory test) per patient, per month.

Calculation of Direct Costs
The health care professional’s (i.e., physician, pharmacist and nurse) time which was utilized by the patient, was estimated by using the work sampling technique to calculate their costs. The cost of the health care professional’s time was estimated by dividing the daily allowance by the number of working hours to get the cost per hour and then, the cost per minute was estimated to multiply it by the time which was utilized by the patient. The data on the transportation fare to the Jaya Gading Polyclinic was collected by interviewing the patients. The principal source of the direct health care costs was the billing division in the Ministry of Health (11),(12).

The direct medical costs were calculated through the summation of the cost produced by multiplying the quantities of each drug and other ambulatory care services by their unit cost (13). The transportation cost for each hypertensive patient was calculated by multiplying the transportation fare reported by the patient during the interview, by the number of visits to the polyclinic.

Calculation of Indirect Costs
Estimation of the indirect costs was based on the human capital approach method, which derives the values of the loss of health from the losses in potential earnings. A visit was estimated to take 0.25 (2 hours) working days lost (14). The cost of productivity which was lost, was calculated by using the following formula (14):

(Number of days lost for each patient) × (2007 Gross National Product ÷ population and by number of working days per year)
All costs were expressed in Malaysian Ringgit (MYR) (MYR 3.20059 = US dollar 1 for the year 2008).

Data analysis
A variety of descriptive statistics such as mean, standard deviation (SD), median and percentage (%) were calculated to describe some parts of the results. The nonparametric test (i.e., Mann-Whitney test) was used to determine the statistically significant differences between the two groups (i.e., controlled and poorly controlled blood pressure) by using the SPSSTM for Windows version 13.

Sensitivity Analysis
Because there might have been some outliers in the study’s population who drove the results, a sensitivity analysis was performed after the exclusion of the patients with the highest and lowest 5% (4) total direct costs and after replacing the drugs costs with maximum values (15) (higher drugs costs) to calculate the new total direct costs which were used in the sensitivity analysis.

Results

The data from 600 patients were analyzed. The mean age of the patients was 54.67 (±9.75). Of all the patients, 84.5% were ≥ 45 years old and 15.5% were < 45 years old. A majority of patients (84.3%) were Malay, followed by Chinese (13.7%), Indians (1.2) and others (0.8%). The Chinese, Indians and other races were treated as “Others” in the analysis because of their small percentage in the whole sample. Females represented approximately two thirds of the patients (67.7%). The demographic and clinical features of the 600 patients are reported in (Table/Fig 1).

(Table/Fig 1): Demographic and Clinical Features

The monthly average direct costs per patient increased progressively across the three stages of hypertension (Table/Fig 2). The average direct costs associated with the poorly controlled blood pressure groups were higher than the average direct costs, which were associated with the controlled blood pressure groups. Medication costs represented the major portion of the total direct costs which were associated with the controlled and the poorly controlled blood pressure groups in the three stages. In the prehypertension stage, the medication costs represented 54.13% and 67.97% of the total direct costs which were attributable to the controlled and the poorly controlled blood pressure groups, respectively. In stage 1, the medication costs represented 55.30% and 67.49% of the total costs and in stage 2, they were (72.55%) and (72.64%), respectively (Table/Fig 4). The transportation costs came after the medication costs, as the next higher cost utilized by both the groups, followed by the costs of the health professionals and the laboratory tests, respectively.

(Table/Fig 2): Monthly Direct and Indirect Costs (MYR) for Hypertensive Patients, Stratified by Blood Pressure Control Status

The monthly average indirect costs associated with the poorly controlled blood pressure groups in stage 1 and stage 2 were higher than the indirect costs which were associated with the controlled blood pressure groups in the same stages.

However, in the prehypertension stage, the indirect costs were higher in the controlled blood pressure group. The highest indirect cost among all poorly controlled blood pressure groups, was seen in stage 1. The highest indirect cost associated with the controlled blood pressure group was that of the prehypertension stage (Table/Fig 2).

(Table/Fig 3) Percentages of Monthly Direct Costs Categories, Stratified by Blood Pressure Control Status

The monthly average direct costs of hypertensive patients showed significant differences between the controlled and the poorly controlled blood pressure groups in all hypertension stages (Table/Fig 4). The results of the sensitivity analysis are shown in (Table/Fig 5). With higher medication costs in both the blood pressure control status groups in each stage, the difference between the direct costs which were associated with the controlled and the poorly controlled blood pressure groups in all stages remained significant (p < 0.001). However, the differences in the indirect costs were not significant.

(Table/Fig 4) Differences in Direct and Indirect Costs (MYR) Stratified by Blood Pressure Control Status

*Mann-Whitney Test

(Table/Fig 5) Differences in Total Direct Costs (MYR), Sensitivity Analysis

*Mann-Whitney Test

(Table/Fig 6) describes the differences between the total costs (i.e., direct and indirect costs) of all patients who were associated with the controlled and the poorly controlled blood pressure groups at each stage of hypertension. The differences between the two groups were MYR 817.68, MYR 1317.66 and MYR 1581.21 in the prehypertension stage, Stage 1 and Stage 2, respectively.

(Table/Fig 6) Differences in Total Costs (MYR) (Direct and Indirect) between Controlled and Poorly controlled BP

Discussion

This study categorized hypertensive patients into two groups based on blood pressure control status in the three hypertension stages. The differences in total monthly average costs between the controlled and the poorly controlled blood pressure groups were analyzed and tested for significant differences. The monthly average total direct costs per patient increased progressively across all the hypertension stages. Additionally, the monthly average total direct costs were found to be significantly higher in the poorly controlled blood pressure groups as compared to the controlled blood pressure groups in the three stages. In the prehypertension stage, the monthly average direct costs were MYR 16.20 and MYR 24.66,which were attributable to the controlled and the poorly controlled groups, respectively. In stage 1, the average direct costs were MYR 17.43 and MYR 28.27 and in stage 2, they were MYR 27.22 and MYR 31.70, respectively. The results of the one-way sensitivity analysis, after adjusting the medication costs to recalculate the total direct costs, showed that the cost of controlled blood pressure was significantly lower than the cost of poorly controlled blood pressure under the three stages of hypertension (p < 0.001). This implies that when the drug costs increased, the direct cost of the patients with controlled blood pressure remained significantly lower, even when the highest drug cost value was used. In a 19-year follow-up study that included the costs of hospitalization and the costs of major drugs, the mean total costs were US$ 132 500 among patients with normal hypertension, US$ 146 500 among patients with mild hypertension, and US$ 219 300 among patients with severe hypertension (5). In addition, there was a significant correlation between higher systolic blood pressure and the cost of increased medications (8).

The results of many studies showed that patients with poorly controlled blood pressure were associated with a higher utilization of health care resources (2),(3),(4),(5),(6),(7),(8),(16). A French study which estimated the cost of treating hypertension in the general practitioners’ clinics, found that the average annual cost of patients with controlled blood pressure was 537€ (US$ 784.61) and the cost of patients with poorly controlled blood pressure was 612€ (US$ 894.19) (6). Paramore et al (8) reported that patients with controlled blood pressure below 130/85 mm Hg accounted for a cost of US$ 325.92. The costs increased to US$ 407.66 for patients in the 130/85 to 139/89 mm Hg con¬trolled group. Patients in the two groups (i.e. poorly controlled hypertension- 140/90 to 159/99 mm Hg and ≥ 160/100 mm Hg) incurred average costs of US$ 430.76 and US$ 577.95, respectively. Their results were significantly different (8). Furthermore, in a study comparing the cost of health care resources for hypertensive patients taking analgesics stratified by having controlled versus poorly controlled hypertension, the annualized costs for emergency-department visits and hospitalizations for the uncontrolled hypertension group were higher than the costs incurred by the controlled hypertension group by 9.3% and 28.0%, respectively (4).

Medication costs represented a major portion of the total direct costs in all controlled and poorly controlled groups, followed by the transportation costs and the costs for health care professionals and the tests, respectively. Antihypertensive drug costs were frequently referred to as an important cost driver in hypertension treatment, as described by other studies (6),(8),(14),(17),(18),(19). Medication costs increased with the severity of hypertension, they were higher in patients with poorly controlled blood pressure than in patients with controlled blood pressure and they increased steadily across the hypertension stages.

Additionally, hypertensive patients with poorly controlled blood pressure were associated with a higher number of polyclinic visits as compared to patients with controlled blood pressure in this study. Similar findings were also reported by other studies (3),(7),(8). The CHOICE study group found that patients with higher blood pressure were associated with a significantly shorter time till the next visit (p < 0.05) and that hypertensive patients with poorly controlled blood pressure had office visits about 13 days earlier than those with controlled blood pressure (7). Moreover, Paramore et al (8) found that the correlation between higher maximum blood pressure and the greater number of physician visits is significant (8).

Indirect costs which were attributable to uncomplicated hypertension which was associated with the poorly controlled blood pressure groups in stage 1 and stage 2 hypertension were higher than the indirect costs which were associated with the controlled blood pressure groups, but the results were not as such in the prehypertension stage. However, the difference was insignificant. Kiiskinen et al. (5) found that patients with severe hypertension lost 2.6 years of work more than did patients with normal hypertension among the males as compared to 2.2years among the females. They concluded that significant losses in terms of years of life lost, years of work lost, and costs are associated with high levels of blood pressure.

Our study results provided estimates of the extra direct and indirect costs incurred by poorly controlled blood pressure, that can be avoided by controlling uncomplicated hypertension in ambulatory care clinics. The data and methodology of this study had some limitations that should be considered when drawing conclusions. The participants of this study were limited to the Malaysian government health care coverage and all of the hypertensive subjects were from the Kuantan city (Jaya Gading area). The health status of the hypertensive subjects may be affected by different factors (e.g., smoking, daily physical activity, etc.).

The results of this study indicate that poorly controlled blood pressure is associated with higher ambulatory care resource utilization. The average direct costs associated with poorly controlled blood pressure were higher than the costs which were associated with controlled blood pressure in the three stages of hypertension. The difference was significant. Furthermore, the differences in the indirect costs between the 3 stages or between the two groups in all the stages of hypertension were not significant.

This study approximated the extra costs due to poorly controlled blood pressure in all stages of hypertension and provided the estimates of the savings that could result from controlling blood pressure. Future studies in Malaysia should consider the impact of poorly controlled complicated hypertension on other resources, such as hospitalizations and emergency department visits.

Funding
This research was funded by a research grant from the Research Management Center, International Islamic University, Malaysia.

Key Message

Controlling hypertension helps in controlling the budgets which were allocated for hypertension in Malaysia.
There is a need to implement aggressive strategies in order to control hypertension in Malaysia.
Information on the economic burden of hypertension in Malaysia is needed to increase the awareness of the need to control hypertension.

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