FOLLOW-UPS AND REFERRALS 79 NMCS PRIMARY CARE 2012 FullReport
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LIST OF TABLES
Table 2.1 Sample size for NMCS 2012
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Table 2.2 Data entry error rate for NMCS 2012
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Table 3.1 Total clinics sampled and responded for NMCS 2012
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Table 3.2 Response rate for NMCS 2012
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Table 3.3 Observed and weighted dataset for NMCS 2012
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Table 4.1 Characteristics of doctors for NMCS 2012
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Table 5.1 Characteristics of patient encounters in primary care clinics in 2012
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Table 5.2 Duration of sick leave issued in primary care clinics in 2012
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Table 6.1 Reasons for encounter by ICPC-2 components in primary care clinics in 2012
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Table 6.2 Reasons for encounter by ICPC-2 components and sector
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Table 6.3 Reasons for encounter by ICPC-2 chapters and common individual reasons
for encounter within chapter in primary care clinics in 2012 36
Table 7.1 Diagnoses by ICPC-2 components in primary care clinics in 2012
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Table 7.2 Diagnoses by ICPC-2 chapters and common individual diagnoses
within chapter managed in primary care clinics in 2012 44
Table 7.3 Thirty most common diagnoses managed in public clinics in 2012
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Table 7.4 Thirty most common diagnoses managed in private clinics in 2012
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Table 8.1 Number of encounters for which medication was prescribed
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Table 8.2 Prescribed medications by ATC level 1, 3 and 5 in primary care clinics in 2012
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Table 8.3 Prescribed medications by ATC level 1 and sector in primary care clinics in 2012
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Table 8.4 Thirty most frequently prescribed medications in public clinics in 2012
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Table 8.5 Thirty most frequently prescribed medications in private clinics in 2012
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Table 9.1 Types of investigations by ICPC-2 chapters and common individual test
within chapter in primary care clinics in 2012 63
Table 9.2 Top 10 diagnoses for which investigation was most frequently ordered
in primary care clinics in 2012 69
Table 10.1 Advicecounselling and procedures in primary care clinics in 2012
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Table 10.2 Types of advicecounseling provided in primary care clinics in 2012
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Table 10.3 Types of procedures performed in primary care clinics in 2012
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Table 10.4 Ten most common diagnoses with advicecounseling
in primary care clinics in 2012 77
Table 10.5 Ten most common diagnoses with procedures in primary care clinics in 2012
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Table 11.1 Follow-up and referrals in primary care clinics in 2012
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Table 11.2 Types of referrals in public clinics in 2012
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Table 11.3 Types of referrals in private clinics in 2012
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Table 11.4 Diagnoses most frequently referred to hospital in 2012
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Table 11.5 Diagnoses most frequently referred to specialist in 2012
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Figure 5.1 Age-gender distribution of patients in primary care clinics in 2012
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Figure 5.2 Mode of payment in primary care clinics in 2012
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Figure 5.3
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Figure 6.1 Number of patient reasons for encounter in primary care clinics in 2012
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Figure 6.2 Top 10 reasons for encounter in public clinics in 2012
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Figure 6.3 Top 10 reasons for encounter in private clinics in 2012
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Figure 7.1 Number of diagnoses managed per encounter in primary care clinics in 2012
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Figure 7.2
JHJHQGHUVSHFLÀFUDWHVRIGLDJQRVHVPDQDJHGSHUHQFRXQWHUV by sector in 2012
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Figure 8.1 Number of medications prescribed per encounter in primary care clinics in 2012
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Figure 8.2
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Figure 9.1 Number of investigations ordered per encounter in primary care clinics in 2012
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Figure 9.2 Top 10 investigations ordered in public clinics in 2012
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Figure 9.3 Top 10 investigations ordered in private clinics in 2012
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Figure 10.1 Ten most common advicecounseling provided in public clinics in 2012
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Figure 10.2 Ten most common advicecounseling provided in private clinics in 2012
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Figure 10.3 Ten most common procedures performed in public clinics in 2012
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Figure 10.4 Ten most common procedures performed in private clinics in 2012
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LIST OF FIGURES
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Acknowledgements
The National Healthcare Statistics Initiative team would like to thank the Director-General of Health, Malaysia for his continuous support for this survey and permission to publish this report.
Also, our sincere appreciation goes to the following for their participation, assistance, support and contribution:
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Swasta, CKAPS
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Malaysia.
We thank the 392 medical doctors from both the public and private primary healthcare clinics who participated in the National Medical Care Survey NMCS between August and November 2012. This
report would not have been possible without their support and contribution from these dedicated professionals.
Last but not least, our greatest appreciation to all those who have supported or contributed to the success of the National Medical Care Survey 2012 and the publication of this report.
Thank you.
National Healthcare Statistics Initiative NHSI Primary Care Team Healthcare Statistics Unit
National Clinical Research Centre Ministry of Health, Malaysia
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NATIONAL MEDICAL CARE SURVEY 2012 PROJECT TEAM
Principal Investigator Datuk Dr. Noor Hisham Abdullah
Principal Co-Investigator Dr. Sheamini Sivasampu
Dr. Goh Pik Pin
Research Evaluation Committee REC Dr. Kamaliah Mohd. Noh
Professor Dr. Khoo Ee Ming Associate Professor Dr. Ng Chirk Jenn
3URIHVVRUU7DXÀN7HQJKHRQJLHQJ Dr. Kaviyarasan Sailin
Associate Professor Dr. Jamaluddin Abdul Rahman Ms. Siti Fauziah Abu
Project Managers Mr. Lim Ka Keat September 2011 – September 2012
Ms. Yvonne Lim Mei Fong Dr. Hwong Wen Yea, Amy
Survey Coordinators Ms. Aisyah Ali
5HVHDUFK2IÀFHUV Ms. Sharmini Chandran
Mr. Shantha Kumar Chandrasekaran Ms. Kasturi Manoharan
Ms. Siti Aminah Ismail Ms. Hanan Hamimi Wahid
Ms. Maryam Nazeera Suhaimi Mr. Poovanesva Rao Yang Ketter Rahman
Data Analysis Ms. Norazida Ab. Rahman
Ms. Yvonne Lim Mei Fong Database DevelopersAdministrators
Altus Solutions Sdn. Bhd.
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ACE Angiotensin converting enzyme
ATC :+2QDWRPLFDO7KHUDSHXWLFKHPLFDOODVVLÀFDWLRQV\VWHP
BEACH Bettering the Evaluation and Care of Health
CI RQÀGHQFH,QWHUYDO
CKAPS Cawangan Kawalan Amalan Perubatan Swasta
DG Director General of Health, Ministry of Health, Malaysia
FMS Family Medicine Specialist
GP General Practice or Practitioner
HbA1c Haemoglobin, type A1c
ICPC ,QWHUQDWLRQDOODVVLÀFDWLRQRI3ULPDU\DUH
IQR Interquartile range
KK Klinik Kesihatan
LCL RZHURQÀGHQFHLPLW
MOH Ministry of Health, Malaysia
MREC Medical Research and Ethics Committee, Ministry of Health Malaysia
NCD Non-communicable disease
NCRC National Clinical Research Centre
NHEWS National Healthcare Establishment Workforce Survey Primary Care
NHSI National Healthcare Statistics Initiative
NIH National Institutes of Health
NMCS National Medical Care Survey
NMUS National Medicines Use Survey
NOS 1RWRWKHUZLVHVSHFLÀHG
REC Research Evaluation Committee
RFEs Reasons for encounter
SOCSO Social Security Organisation
UCL 8SSHURQÀGHQFHLPLW
UKAPS Unit Kawalan Amalan Perubatan Swasta
WHO World Health Organisation
WONCA World Organization of National Colleges, Academies and Academic Associations
of General PractitionersFamily Physicians WP
Wilayah Persekutuan
ABBREVIATIONS
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- Not applicable
More than
More than or equal to Less than
Percentage
SYMBOLS
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EXECUTIVE SUMMARY
The National Medical Care Survey NMCS is a provider-based survey, which aims to study the characteristics and morbidity pattern of patients, as well as healthcare activities in terms of investigations,
procedures, counselling and visit disposition provided at primary care level in Malaysia.
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to region and sector, and selected through random sampling. Doctors from these clinics were asked to JLYHGHWDLOVRQSDWLHQWVWKH\VDZRQRQHVSHFLÀFGD\ZKLFKZDVUDQGRPO\DOORFDWHGEHWZHHQXJXVWWR
November 2012.
This report presents data collected from 69 public clinics and 120 private clinics.
Doctors working at primary care clinics
A total of 408 doctors participated in NMCS 2012; 259 63.5 from public clinics and 149 36.5 from private clinics. Of these, 350 doctors provided their socio-demographic details 229 public doctors and 121
private doctors. RIWKHUHVSRQGHQWVZHUHIHPDOHV+LJKHUSURSRUWLRQRIIHPDOHVZDVVHHQLQSXEOLF
clinics 76.4; 175229 as compared to private clinics 39.7; 48121. OPRVWKDOIRIWKHGRFWRUVLQSXEOLFFOLQLFVDQGLQSULYDWHFOLQLFVDJHGEHWZHHQWR
39 years old. On the contrary, 62.8 of the doctors in private clinics and 6.9 in public clinics were over 50 years old.
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Patients seen at primary care clinics
There were 141,593 patient encounters recorded for NMCS 2012; 42,340 encounters 29.9 were from public clinics and 99,253 encounters 70.1 from private clinics.
RIWKHSDWLHQWVVHHQZHUHIHPDOHVLQSXEOLFFOLQLFVDQGLQSULYDWHFOLQLFV 7KHPHGLDQDJHRISDWLHQWVZDV\HDUVDQGWKHDJHGLVWULEXWLRQZHUHDVIROORZV,QIDQWV\HDU
\HDUV\HDUV\HDUV\HDUVDQG\HDUV 11.5.
7KH DJH GLVWULEXWLRQV RI SDWLHQWV VHHQ LQ SXEOLF DQG SULYDWH FOLQLFV ZHUH VLPLODU EXW D ODUJHU percentage of older patients were seen in public clinics where 20.7 of patients in public clinics and
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others 5.6. RISDWLHQWVVHHQLQSULYDWHFOLQLFVSDLGRXWRISRFNHWDQGSDLGE\WKLUGSDUW\SD\HUV
such as insurance. Visits to public clinics were all subsidised by government with a minimal charge of RM1 per encounter and is free for patients older than 60 years.
0HGLFDOFHUWLÀFDWHZHUHLVVXHGWRRISDWLHQWVLQSXEOLFFOLQLFVLQSULYDWHFOLQLFV The duration of sick leave ranged from half day to 21 days.
Reasons for seeking treatment at primary care clinics
Reason for seeking treatment is also otherwise known as reasons for encounter RFEs. From the 141,593 patient encounters, 233,326 RFEs were recorded; 73,616 31.5 in public clinics and 159,710 68.5 in
private clinics. Overall, there were 165 RFEs for every 100 patient encounters.
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7KHPRVWFRPPRQ5SUHVHQWHGLQSXEOLFFOLQLFVZDVIROORZXSRUWUHDWPHQWIRUK\SHUWHQVLRQWKDW made up 17.7 13,028 of all RFEs 31 per 100 encounters. This was followed by diabetes 20 per
100 encounters and lipid disorder 19 per 100 encounters. VIRUSULYDWHFOLQLFVIHYHUDQGFRXJKZHUHWKHPRVWFRPPRQ5VDQGERWKZHUHUHFRUGHGDWDUDWH
of 25 per 100 encounters. Abdominal pain was the third highest and seen in 10 out of 100 encounters.
Types of diagnosis
Of the 141,593 patient encounters at primary care clinics, 188,944 diagnoses were made with average 133 diagnoses made per 100 patient encounters. In public clinics, there were 68,877 diagnoses 36.5 at a
rate of 163 diagnoses per 100 encounters. Private clinics managed 120,067 diagnoses 63.5 at a rate of 121 diagnoses per 100 encounters.
3DWLHQWVVHHQLQSXEOLFFOLQLFVZHUHPRVWO\IRUWUHDWPHQWRIQRQFRPPXQLFDEOHGLVHDVHVRUHYHU\
100 patient encounters, 33 had the diagnosis of hypertension and it was the commonest diagnosis. This was followed by lipid disorder 22 per 100 encounters and diabetes 24 per 100 encounters. In
private clinics however, hypertension diagnosis was made in only 5 out of 100 encounters, diabetes in 3 per 100 encounters and lipid disorder in 2 per 100 encounters.
\ FRPSDULVRQ PDMRULW\ RI WKH FDVHV ZKLFK SULYDWH SULPDU\ FDUH SURYLGHUV VDZ ZHUH IRU DFXWH illnesses. The most common diagnosis in private clinics was upper respiratory infection that
contributed to 21.5 of all diagnoses in private clinics and diagnosed in 26 out of 100 encounters. Gastrointestinal infection was the second most common diagnosis, though it only constituted 5.0
of diagnoses 6 per 100 encounters.
Medications prescribed
A total of 479,856 medications were recorded, at an average of 254 medications per 100 encounters and 190 medications per 100 diagnoses. Public clinics prescribed a total of 130,484 medications 244 per
100 encounters; 150 per 100 diagnoses and private clinics prescribed 255,788 medications 258 per 100 encounters; 213 per 100 diagnoses.
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and 90.3 in private clinics. ,QSXEOLFFOLQLFVPHGLFDWLRQVPRVWFRPPRQO\SUHVFULEHGZHUHSDUDFHWDPROSHUHQFRXQWHUV
metformin 17 per 100 encounters, amlodipine 16 per 100 encounters, lovastatin 15 per 100 encounters, and perindopril 13 per 100 encounters.
7KHWRSÀYHPHGLFDWLRQVSUHVFULEHGLQSULYDWHFOLQLFVZHUHSDUDFHWDPROSHUHQFRXQWHUV diphenhydramine 10 per 100 encounters, diclofenac 9 per 100 encounters, chlorphenamine 8 per
100 encounters, and butylscopolamine 8 per 100 encounters.
Investigations ordered
There were 53,028 investigations recorded, of which 64.4 was ordered by doctors at public clinics. The average rate of investigation ordered was 38 per 100 encounters; public clinics had 81 investigations per
100 encounters and private clinics had 19 investigations per 100 encounters. 0DMRULW\RIWKHLQYHVWLJDWLRQVUHFRUGHGZHUHODERUDWRU\WHVWVLDJQRVWLFUDGLRORJ\LPDJLQJ
test constituted 21.4 of all investigations. ,QSXEOLFFOLQLFVJOXFRVHWHVWZDVWKHPRVWIUHTXHQWO\RUGHUHGLQYHVWLJDWLRQSHUHQFRXQWHUV
In private clinics, urine test was most common 4 per 100 encounters. LDEHWHVK\SHUWHQVLRQDQGOLSLGGLVRUGHUZHUHWKHPRVWFRPPRQGLDJQRVHVIRUZKLFKLQYHVWLJDWLRQV
were ordered.
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Advicecounselling and procedures
There were 36,782 advicecounselling 26 per 100 encounters and 3,607 procedures 3 per 100 encounters recorded in 2012.
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in private clinics. PRQJWKHW\SHVRIDGYLFHFRXQVHOOLQJSURYLGHGLQSULPDU\FDUHFOLQLFVZHUHJHQHUDODGYLFH
HGXFDWLRQRQGLHWPHGLFDWLRQVÁXLGVLQWDNHDQGK\JLHQH RIWRWDOSURFHGXUHVZHUHSHUIRUPHGLQSXEOLFFOLQLFVZKLOHWKHUHVWZHUHGRQHLQ
private clinics. UHVVLQJZDVWKHPRVWFRPPRQSURFHGXUHUHFRUGHGDQGDFFRXQWHGIRURIDOOSURFHGXUHV
performed in primary care clinics.
Follow-up and referrals
There were 46,043 patient encounters 32.5 arranged for follow-up after visit to primary care clinics. Arrangements for follow-up were made more frequent in public clinics 63 out of 100 encounters compared
to private clinics 19 out of 100 encounters.
Referral was provided for 5,873 patient encounters 4.1 during visit to primary care clinics. Similar to follow-up, the referral rate was higher in public clinics 7 per 100 encounters than private clinics 3 per
100 encounters. 5HIHUUDOVZHUHPRVWRIWHQPDGHWRKRVSLWDOSHUHQFRXQWHUVDQGVSHFLDOLVWSHU
encounters. OOUHIHUUDOVWRDOOLHGKHDOWKSURIHVVLRQDOVZHUHPDGHE\SXEOLFFOLQLFV
PRQJDOOGLDJQRVHVUHIHUUHGWRKRVSLWDOKLJKULVNSUHJQDQFLHVZHUHWKHPRVWFRPPRQ LDEHWHVPHOOLWXVZDVWKHPRVWIUHTXHQWGLDJQRVLVUHIHUUHGWRDVSHFLDOLVW
These data are by far the most comprehensive and detailed information on health care activities of both the public and private primary care clinics in Malaysia. Although the study was restricted to only clinics
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together with those from the National Healthcare Establishment and Workforce Survey: Primary Care NHEWS are vital to form a clearer picture of the current primary healthcare system in Malaysia.
Chapter 1
Introduction
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