Journal of Health Systems Research

Journal of Health Systems Research
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Website: http:// www.hsri.or.th
Editorial Board
The Journal of Health Systems Research is a publication of the Health Systems Research
Institute, Thailand for the presentation of current academic knowledge and research works, particularly on public health systems. It is published quarterly in March, June, September and
December
Editorial Board
Honorary Advisors
Prawase Wasi
Vicharn Panich
Thep Himathongkam
Wichit Srisuphan
Juree Vichit-vadakan
Mongkol Na Songkhla
Nawaaporn Ryanskul
Pongpisut Jongudomsuk
Editor
Paibul Suriyawongpaisal
Associate Editor
Sorachai Jamniandamrongkarn
Members
Nawanan Theera-Ampornpunt
Samrit Srithamrongsawat
Phudit Tejativaddhana
Surasak Buranatrevedh
Thira Woratanarat
Suwat Chariyalertsak
Nuntavarn Vichit-Vadakan
Jomkwan Yothasamut
Pongthep Wongwacharapaibul
Journal Manager
Wanpen Tinna
Faculty of Medicine Ramathibodi Hospital, Mahidol University

Health Systems Research Institute
Health Insurance System Research Office
Faculty of Public Health, Naresuan University
Faculty of Medicine, Thammasat University
Faculty of Medicine, Chulalongkorn University
Research Institute for Health Sciences, Chiang Mai University
Faculty of Public Health, Thammasat University
Health Intervention and Technology Assessment Program
Social Medicine Unit, Nan Hospital
Health Systems Research Institute
Office Health Systems Research Institute

4th Floor, National Health Building, Public Health 6 Road,
Ministry of Public Health, Muang District, Nonthaburi 11000
Tel. (662) 832 9200
Fax (662) 832 9201-2
Website: http:// www.hsri.or.th
.-.

Vol. 6 No. 2 Apr. - Jun. 2012
Contents
135
EDITORS NOTE
REVIEW ARTICLES
: 136
Drug price control: Lessons from the past, present

findings and recommendations for the future
Supon Limwattananon
Chulaporn Limwattananon
On-anong Waleekhachonloet
Pornpit Silkavute
Phusit Prakongsai
Weerasak Puthasri
Viroj Tangcharoensatien
14
144
Surasak Buranatrevedh
Viwat Puttawanchai
Wisree Wayurakul
Junya Pattaraarchachai
ORIGINAL ARTICLES
156
: 167

Urban Primary Care System in 14 countries
A review of drug pricing control system in

Thailand
On-anong Waleekhachonloet
Thananan Rattanachotphanit
Pornpit Silkavute
Thanaporn Chaijit
Kwansuda Chadsom
Quality of Out-Patient Prescribing: An Analysis of

18 Standard File Datasets of Hospitals
Areewan Cheawchanwattana
Onanong Waleekhachonloet
Thananan Rattanachotphanit
Pimprapa Kitwitee
Ratchata Unlamarn
Waraporn Saisunantararom
Somchai Suriyakrai

.-.

Vol. 6 No. 2 Apr. - Jun. 2012
Contents
176
185

193
207
219
Drug pricing measures for the reimbursement

Cha-oncin Sooksriwong
Wansuda Ngam-Aroon
Sunchai Janto
Determination of 2010 Reimbursed Drug Price

and Its Budget Impact in Public Hospitals in Thailand
Petcharat Pongcharoensuk
Angkana Saengnapakas
Oraluck Pattanaprateep
Hematopoietic stem cell transplantation in severe

thalassemic patients in two university hospitals
in Bangkok: Experiences of caregivers
Surachai Kotirum
Pattara Leelahavarong
Kleebsabai Sanpakit
Suradej Hongeng
Yot Teerawattananon
Sripen Tantivess
Responsiveness under different health insurance

schemes and hospital types
Aungsumalee Pholpark
Yongyuth Pongsupap
Wichai Aekplakorn
Samrit Srithamrongsawat
Rachanee Sunsern
Rural retention of medical graduates trained by

the collaborative project to increase rural doctors
(CPIRD)
Nonglak Pagaiya
Lalitthaya Kongkam
Warangkhana Worarat
Sanya Sriratana
Krisada Wongwinyou
.-.
228
236
:
248
:
260
268
278

Vol. 6 No. 2 Apr. - Jun. 2012
Contents
Impacts of financial measures on retention of doctors in rural and public health facilities
Nonglak Pagaiya
Sanya Sriratana
Krisada Wongwinyou
Chiraporn Lapkom
Warangkhana Worarat
Good Governance Mechanisms for Medical Profession Regulations in the United Kingdom, New
Zealand and South Africa
Paisan Limstit
Relationship and relative risk of cardiovascular

diseases attributable from smoking: A systematic
review and meta-analysis
Jiraboon Tosanguan
Suchunya Aungkulanon
Hathaichanok Sumalee
Kanitta Bundhamcharoen
Physicians attitudes, obstacles, and sources about

the use of cost-effectiveness information in clinical practice in Thailand: a cross-sectional survey
Win Techakehakij
Rungrote Subsoontorn
Nutthawut Chuaihom
Mallika Bunneum
Nalat Yingtaweewattana
Primrata Chumsri
Why dont Chiangmai people in need call emergency medical service?

Natcha Hansudewechakul
Boriboon Chenthanakij
Borwon Wittayachamnankul
Scoping Review and Research Synthesis on the

Financial Management of Oral Health Promotion
System for the Disabled in Thailand
Jutharat Chimruang
Nithimar Sermsuti-Anuwat
.-.

Vol. 6 No. 2 Apr. - Jun. 2012
. .

Contents
290
Development of Diabetic Care System in Pua

Contracting Unit for Primary Care, Nan Province
Kobkul Yodnarong
.-.

..
,
%
- %

(Reference Pricing), Value Based Pricing, Price
Volume Agreement

( . )

.-.
*,
*

(..-)

: , OECD,
Abstract
Drug price control: Lessons from the past, present findings and recommendations for the future
Supon Limwattananon*,, Chulaporn Limwattananon*, On-anong Waleekhachonloet, Pornpit

Silkavute, Phusit Prakongsai, Weerasak Puthasri, Viroj Tangcharoensatien
*Faculty of Pharmaceutical Sciences, Khon Kaen University, International Health Policy Program, Faculty of
Pharmacy, Mahasarakham University, Health Systems Research Institute
Drug price control is one of the measures to contain health care costs. This paper briefly reviewed
the price control methods that have been commonly employed in developed countries. Experience in
136
Vol. 6 No. 2 Apr.-Jun. 2012
controlling drug prices by government agencies in Thailand was analyzed and recent findings from the
Research Projects on Drug Prices (B.E. 2553-2555) that have been supported by the Health Systems Research Institute were summarized. Policy recommendations for the control of both purchased and reimbursed prices were additionally proposed. The National Lists of Essential Medicines should be strategically mobilized as an indirect measure of price control. To control the purchased prices of new drugs,
innovative strategies of pool purchasing and price negotiation should be implemented under collaboration with health insurance funds. Routine monitoring of the hospital-purchased prices should be supported so as to obtain the regular and update information on drug pricing. The reimbursed price of a
generic drug that is covered by the National Lists of Essential Medicines should be set at an adequately
high rate that can incentivize the use. An agency for the development and maintenance of standardized
drug databases should be established. The long-run development should include the price monitoring
infrastructure in every step, from essential drug selection, drug purchasing, utilization and reimbursement.
Keywords: Drug pricing control, OECD countries, government sector
..

()

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(gross domestic product)()

.. ,

()

..
()

()

Organization for Economic Cooperation and Development (OECD)
(reimbursed price)

.-.

(demand)
(orphan drug)

OECD

(generic drug)
()

(supply chain)
()
. (external price
benchmarking)

. (internal reference pricing)

(reference price)

. (cost-plus pricing)

-
()
. (profit control)

( .. )

138
()
(Patented Medicine
Prices Review Board)
-
(Category )
- (Category )
- Category :
- Category :

- //
(French Transparency
Commission)
-
(Category )
- (Category )
- (Category )
- /
(Category )
- (Category )
- Category :
- Category -: Economic Committee

for Health Products National
Union of Sickness Insurance Funds
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, , ), ,

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(Ministry of Health and

Labor)
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-%
- (usefulness premium): %
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-%
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- : %
.
- .
-
.
.
- (Marketability I)
- (Marketability II)
: OECD ()
.-.
(
)
.

(..-)
(compulsory licensing)

Efavirenz,
Lopinavir/Ritonavir, Clopidogrel, Imatinib, Erlotinib,
Letrozole Docetaxel

()

( Clopidogrel Docetaxel)

(.) ..

(
DMSIC)
140

()
()()

simvastatin rosuvastatin

()

Anatomical, Therapeutic and Chemical (ATC) defined
daily dose (DDD)
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; ()
; () ; ()

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(supply)

(reimbursed lists)

. . 2548-2550
[on line]. 2548 [cite 2011 Feb 14] Available from: URL: http://
www.hiso.or.th/hiso/picture/reportHealth/ThaiHealth2005- 2007/report2005-6- 4.pdf
. , .
. ;
.
. Lu ZJ and Comanor WS. Strategic pricing of new pharmaceuticals. The Review of Economics and Statistics 1998;80(1):108-118.
. Tangcharoensathien V, Limwattananon S, Patcharanarumol W,
Vasavid C, Prakongsai P, Pongutta S. Regulation of health service
delivery in private sector: challenges and opportunitites. Technical
partner paper 8.The Rockefeller Foundation-sponsored initiative
on the role of the private sector in health systems in developing
countries. International Health Policy Program (IHPP); 2009.
142
. OECD Health Policy Studies. Pharmaceutical Pricing Policies in a

Global Market. France: OECD Publication; 2008.
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14

(Primary Care Evaluation Tool : PCET of WHO European Region)
(gatekeeper)

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Abstract
Urban Primary Care System in 14 countries
Surasak Buranatrevedh*, Viwat Puttawanchai*, Wisree Wayurakul*, Junya Pattaraarchachai*

*Faculty of Medicine, Thammasat University
People living in urban areas are growing; therefore, urban primary medical care is more crucial.
Studying urban primary care systems in various countries will make us learn from best practice in each
country which may be applied to Thai urban medical system. Objectives of this study were to analyze and
compare urban primary care systems among each country. Study design was documentary research about
urban primary care systems in 14 countries including Brazil, Canada, Spain, Cuba, Republic of Korea,
Japan, Taiwan, Hong Kong, Denmark, Sweden, Belgium, United Kingdom, United States of America, and
Australia. Primary Care Evaluation Tool (PCET) of WHO European Region was used as a framework for
analysis. From this study, countries with gatekeeper system (patients were screened by general practitioners or family physicians ) had good continuous, collaborative, and coordinate care with appropriate
health care costs. Most of countries which governments spent budget for peoples medical care expenses
had provided general practitioners or family physicians as gatekeepers acting in patients screening. There
was no gatekeeper system in countries which people were responsible for their own medical care expenses but co-payment system was involved to reduce unnecessary service uses.
Keywords: primary care, urban primary care, primary care system, urban primary care system
144

(Primary Care Evaluation Tool: PCET of
WHO European Region)()
() Stewardship

() Resource Generation

(evidence-based medicine)
stewardship () Financing

financing

() Service Delivery

..

.. -
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)
.. .
(. )
(megacities)
.
.. . .. ()

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access to services, continuity of services, coordination of delivery comprehensiveness
.
.
.
.
.

.
.
(-)

(gatekeeper)

Good Practice/
.

.

/

(-)
Brazilian Unified Health System (Sistema

Unicode Saude: SUS)
Family Health Programme

Family Health Care

-
,
gatekeeper
Good Practice/
. decentralization

. Family Health
Programme

.
P4P

146
.
CHT (Canada
Health Transfer)
(purchaser) providers
.
(rigid)

.
(gatekeeper)
()

Primary care team
(PCT)
(gatekeeper)
Good practice/
.

.
(,)
health
councils

Good practice/
.
(
)
.

consultorio
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National Health Insurance

(NHI)

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Good practice/
.

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(solo practice)
/
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(guideline)
. fee for
service

()
.

gate keeper
148

()
()

Good practice/
. (medical network
reform)

(medical care development fund)

. (health insurance reform)

(single fund)

(co-payment)

. (health information reform)

. (family physicians development)

. Integrated Community Health

Care Service Network Health stations
community medical care network (

health station

)

()

.-.

Good practice/
.
()

group group
group

group group

group

Good practice/
.
.
group group
. gatekeepers
()
Good practice/
.
()
(Sickness funds)

(Maximum billing-MAB)
150
Good practice/
.
.
gatekeeper
. ( .
GDP)
()
(National Health ServiceNHS) ..

NHS
NHS (Primary
care trusts-PCTs)

(gatekeeping role)
Good practice/
.
.

/
.
(-)
(public-private mix)
(universal health care system)

gatekeeper
/
Good practice/
.
.
. ..
. GDP
..
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Good practice/
.
.
.
GP superclinics
First contact/
Gatekeeper
gatekeeper

gatekeeper

gatekeeper

gatekeeper
gatekeeper
gatekeeper
gatekeeper

gatekeeper

gatekeeper
gatekeeper

gatekeeper
gatekeeper

gatekeeper
Continuity
Collaboration/
Comprehensiveness
Coordination

152
(gatekeeper)
(continuity) (collaboration/coordination)
.
.

. Stewardship

. Resource generation and distribution

. Financing and incentives

.
.
.

/
.-.
tive Republic of Brazil, 2008-2012. / Pan-American Health Organization. - Brasilia; 2007.

Victora CG. Health conditions and health policy innovations in
Brazil: the way forward. Lancet 2011;377:2042-51.
. World Health Organization. Country cooperative strategy at a glance:
Brazil. World Health Organization. 2009 [Accessed November 10,
2011]. Available from: http://www.who.int/countryfocus
. World Health Organization. Flawed but fair: Brazils health system reaches out to the poor. Bulletin of the World Health Organization. 2008;86(4).
. Canadian Institute for Health Information, Health Care in Canada
2010. Ottawa, Ont.: CIHI; 2010.
. Canadian Institute for Health Information, Improving the Health of
Canadians: An Introduction to Health in Urban Places. Ottawa,
Ont.: CIHI; 2010.
. Canadian Institute for Health Information, National Health Expenditure Trends, 1975-2010. Ottawa, Ont.:CIHI; 2010.
. Derape R, Gauthier J. Canada health transfer: Equal-Per-Capita
cash by 2014. In Current and Emerging Issues for the 41th Parliament. Ottawa: Library of Parliament; 2010.
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health of Canadians living in census metropolitan areas. Ottawa:
Statistics Canada; 2004.
. Hay D, Varga-toth J, Hines E. Frontline health care in Canada:
innovations in delivering services to vulnerable population. Ont.:
Canada Policy Research Networks; 2006.
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. Herbert R, Canadas health care challenge: Recognizing and Addressing the Health Needs of Rural Canadians. Lethbridge Undergraduate Research Journal. 2007. Volume 2 Number 1.
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2010]. Available from: http://www.parl.gc.ca/Content/LOP/Research
Publications/944-e.htm#issuetxt.
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1, 2010]. Available from: www.medicare.ca.
. Stattistics Canada, 2006. Census population; Canada Post Corporation, May 2006.
. Garca-Armesto S, Abada-Taira MB, Durn A, Hernndez-Quevedo
C, Bernal-Delgado E. Spain: Health system review. Health Systems in Transition 2010;12:1-295.
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L. Family medicine in Cuba: community-oriented primary care
and complementary and alternative medicine. J Am Board Fam
. Delivery of care

/.

(.)
. Vlahov D, Galea S. Urbanization, urbanicity, and health. Journal

of Urban Health: Bulletin of the New York Academy of Medicine.
2002;79 (Suppl. 1):S1-12.
. Donaldson MS, Yordy KD, Lohr KN, Neal A. Vanselow, editors.
Primary Care: Americas Health in a New Era. Washington DC:
Institute of Medicine;1996.
. . CUP management:
. :
; .
. World Health Organization: Regional Office for Europe. Primary
Care Evaluation Tool [Internet] 2011 [Accessed March 24, 2011].
Available from: http://www.euro.who.int/en/what-we-do/health-topics/
Health-systems/primary-health-care/publications/2010/primary-careevaluation-tool-pcet.
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I: an outline of Brazils health care system reforms. J Public
Health 1996;18:289-95.
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2003;93:44-8.
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society. Lancet 2011;377:1724-5.
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health program in Brazil. Cad. Sade Pblica, Rio de Janeiro
2006;22:2549-59.
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154
Pract 2005;18:297-303.
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Health system review. Health Systems in Transition 2009;11:1184.
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Health Econ Policy Law 2011;6:85-107.
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Hong Kong: strategy document; 2010.
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Vrangbk K, Mossialos E. Denmark: Health system review. Health
Systems in Transition 2007;9:1-164.
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Health systems in transition: Sweden. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory
on Health Systems and Policies 2005;1-130.

. Gerkens S, Merkur S. Belgium: Health system review. Health
. Boyle S. United Kingdom (England): health system review. Health
. Cutler DM. The American health care system. Medical Solutions
2008:2-6.
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Reform: Issues for Consumers and States Prepared for State Coverage Initiatives by the Urban Institute. March 2011.
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Content in MEPS Chartbook No. 13. Agency for Health Care
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Available from: http://www.ahrq.gov/data/meps/chbook13up.htm.
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Health Systems in Transition 2006;8:1-158.
.-.
: ,
Abstract
A review of drug pricing control system in Thailand

On-anong Waleekhachonloet*, Thananan Rattanachotphanit*, Pornpit Silkavute, Thanaporn Chaijit,
Kwansuda Chadsom, Chulaporn Limwattananon
*Faculty of Pharmacy, Mahasarakham University, Health Systems Research Institute, Nonghan Hospital,
Udonthani, Faculty of Pharmaceutical Sciences, Khon Kaen University
This study focused on a review of the national system for drug price policy. Methods including
interviewing key persons in various organizations, meetings with experts, studying related documents
and literatures, were used. The study revealed that Ministry of Public Health (MOPH hospitals) had several indirect drug price control mechanisms for government sector especially for the MOPH hospitals
156
themselves. Drug price control has been started in the process of national essential drug list (ED) selection. Cost effectiveness and budget impact analyses were parts of the consideration criteria. After drugs
were selected as the ED, median price would be set as the price control measure for procurement process
of MOPH hospitals. In addition, central negotiation was used for controlling price of single source nonessential drugs in MOPH hospitals. National Health Security Office takes the leading role in price negotiating of high cost ED to ensure accessibility for their beneficiaries. However, limited items were negotiated in each year. Group purchasing in level of provinces and regions was not much expanded from the
past.
There exists no autonomous body and no regulation for controlling of manufacturer price setting
before drug registration processes. No regulation and system for controlling mark up in private sector
have been implemented. Selling price was controlled to not more than price list. For drug price monitoring, only voluntary reporting of MOPH hospital purchasing price was available under the Drug and
Medical Supply Information Center (DMSIC).
As the ways to improve drug price control system in Thailand, manufacturer production cost structure should be submitted as the condition for national essential drug list consideration. In terms of negotiation, knowledge management of negotiation and purchasing strategies, expanding of items for central
negotiation for all three health insurance schemes are encouraged. Drug price setting for procurement
and a monitoring system should be improved. Moreover, a study on adverse effects of drug price control
system on domestic pharmaceutical industries is necessary.
Keywords: Drug price control, Health insurance system

(original)

()

()

() ()

()
.-.

Pharmacy Pricing and Reimbursement Information (PPRI)Pharmacy Profile()

()
.
( )
(.)
(diagnosisrelated group, DRG)
(capitation)

.
(
)

(inclusive capitation)

.

DRG
(fee for service, FFS)
.
()

()

158

( )
(
)

..

(copayment) (reference price, RP)
FFS

( )

(clinical practice guidelines, CPG)

-

(effective list)
(reimbursable list)
.-.
(Essential Drug Lists)

,

ISaFE (InformationSafety-Administration restriction-Frequency-Efficacy)
EMCI (Essential Medicine Cost Index)

(incremental cost-effectiveness ratio, ICER)

(quality-adjusted life year, QALY)
()

reimbursable
list
FFS
..
()
160

(monopoly)

(compulsory licensing, CL)

( )

(secured demand)
(advanced market commitment)

(,)
.

-

., clopidogrel, deferiprone, oseltamivir

()

.

monopoly value-based
pricing
.

(one price one list)

.-.

.,
.
(e-claim)

(
)

(
)

ceftazidime 1 g injection

(.. -)

Efavirenz, Lopinavir/Ritonavir,
Clopidogrel, Imatinib, Erlotinib, Letrozole Docetaxel

162

() ( Clopidogrel
Docetaxel)

(.. -)
()

(ex-factory)
(free pricing)

internal price referencing, external price
referencing, cost plus pricing indirect profit control
.. ()

(DMSIC)

website

DMSIC
-

sector
.-.

.
. ()

chain store
competitive pricing

mark up -
mark up single source
- generic mark up

FFS

mark up

..
/ ,
/ /

()
164
monopoly
. DIUS (2007b). The R&D Scoreboard 2007: The Top 850 UK and
1250 Global Companies by R&D Investment Main Data Tables,
London.
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Global Market. France: OECD Publication; 2008.
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Commission, Directorate-General Health and Consumer Protection
and Federal Ministry of Health and Womens Issues, Austria;
2006.
. .
. : . .
.
.
. . [on line]. 2553
.-.
[ 5 2555]. : URL: http://hrm.moph.go.th/

res53/res-rep2553.html
. 2548-2550
[on line]. 2548 [cite 2011 Feb 14] Available from: URL: http://
www.hiso.or.th/hiso/picture/reportHealth/ThaiHealth2005- 2007/report2005-6- 4.pdf
[on line]. 2547 [ 28
2554]. : URL: http://www.thaifda.com/ed2547/
?pg=manual
[on line]. 2551 [ 6
2554]. : URL: http://dmsic.moph.go.th/download/mp51_251151.pdf.
.
. . ;
.
()
[on line]. 2554 [ 5 2555]. : URL: http:/
/dmsic.moph.go.th/news/detail.php?idnews=3120.

[on line]. 2554 [ 6
2554] : http://drugfund.nhso.go.th/drugfund/webfiles/
images/17022012104754-page118-120.pdf
. , , , ,
, .
. :
; .
. .. 2542 [on line].
[ 6 2554]. : URL: http://www.dit.go.th/
aboutdetail.asp?catid=103370101&ID=1093.
. .. 2554
.. 2554 - 2557 [on line]. [ 6
2554]. : URL: http://wwwapp1.fda.moph.go.th/drug/
zone_service/files/NDP%20from%20cabinet14Mar11.pdf
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in Thailand [on line]. [cited 2011 Sep 10 Available from: URL:
http://www.haiweb.org/medicineprices/surveys/200610TH/sdocs/
survey_report.pdf
. [on line]. [ 6 2554].
: URL: http://www.thailog.org/wikilog/logistics/import-exportcustoms/2010-12-23-03-52-17/2010-12-23-06-00-34.html
166
.-.
:

*

*
#
*

SQL

()
() () angiotensin converting enzyme
inhibitors (ACEIs) angiotensin II receptor blockers (ARBs) statins

ACEIs/
ARBs statins

: , , ,
Abstract
Quality of Out-Patient Prescribing: An Analysis of 18 Standard File Datasets of Hospitals

Areewan Cheawchanwattana*, Onanong Waleekhachonloet, Thananan Rattanachotphanit, Pimprapa
Kitwitee, Ratchata Unlamarn, Waraporn Saisunantararom#, Somchai Suriyakrai*, Chulaporn
Limwattananon*
*Faculty of Pharmaceutical Sciences, Khon Kaen University, Faculty of Pharmacy, Mahasarakham University,
Saraburi Hospital, Ubolratchathanee Hospital, #Nachauk Hospital, Mahasarakam
Rational drug use would lead to sustain health care financing. Currently, most hospitals have prescribing data recorded in standard electronic databases. However, an analysis of these electronic data-
.-.
bases providing a performance feedback on quality of prescribing is limited. The analysis algorithms to
assess prescribing indicators for 18 standard files on out-patient services using SQL program were developed. Pharmacists and computer staff from 134 hospitals voluntarily attended the 3-day training sessions.
We reported the results of analyses of fiscal year 2553 data of the 88 attending hospitals. The information
presented could be used to guide not only health care settings, but also health policy makers, in terms of
rational antibiotic prescribing for common cold and diarrhea, inhaled coticostroid (ICS) prescribing for
asthma patients, and angiotensin converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers
(ARBs), and statins prescribing for diabetes patients.
More than half of hospitals had greater than 50% of oral antibiotic prescriptions in common cold,
and quinolones prescriptions in non-infected diarrhea. ICS prescriptions in asthma patients, and ACEIs/
ARBs and statins in diabetes patients were moderately prescribed. However for the latter two conditions
high variations across hospitals were found. The findings urge that all hospitals should promote analysis
of the hospital electronic database to obtain the feedback information, which in turn can guide the implementation of activities to increase quality of prescribing, at least for the reported conditions.
Keywords:
Prescribing quality, Prescribing indicator, Prescribing database, 18 standard files for out patient service

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diabetic nephropathy ACEIs
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ARBs statins
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oral antibiotics

oral antibiotics
- -
Antimicrobial prescriptions
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NE19 NE31
N14
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N5
NE20
S44
S57
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20
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10
20
30
40
50
60
70
80
90
100
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Note: Circle size proportional to total number of outpatient visits with common cold and diarrhea
.-.
Asthma: Inhaled corticosteroid use

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50
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. World Health Organization. Keys components of a well functioning health system. [online]. 2010 May[cited 2012 Apr 1]; Available from: URL: http://www.who.int/healthsystems/EN_HSS
keycomponents.pdf
.
.
18
. [online]. [cited 2012 Apr 1]; Available from: URL:http:/
/203.157.10.11/web2011/sphp/std18.php

. [online]. [cited 2012
Apr 1]; Available from: URL: http://pharm.kku.ac.th/thaiversion/
?page_id=938
Antibiotic Smart Use.
[online]. [cited 2012 Apr 1]; Available from: URL: http://newsser.
fda.moph.go.th/rumthai/asu/introduce.php
.
ASU Version 1.0 December 2009 -. [online]. 2009
December [cited 2012 Apr 1]; Available from: URL: http://
newsser.fda.moph.go.th/rumthai/userfiledownload/asu109dl.pdf
World Health Organization. International statistical classification
of diseases and relatedhealth problems. 10th Revision version for
2007 [online]. 2007 [cited 2012 Apr 1]; Available from: URL:
http://www.crhospital.org/media/doc/ICD10_WHO_2007_TnI.pdf
.
ASU Version 1.0 December 2009 ACUTE DIARRHEA.
[online]. 2009 December [cited 2012 Apr 1]; Available from:
URL: http://newsser.fda.moph.go.th/rumthai/userfiledownload/
asu109dl.pdf
.
Easy Asthma Clinic
. [online]. [cited 2012 Apr 1];
Available from: URL:http://eac2.dbregistry.com/site_data/
dbregistry_eac/1/file/Watchara/EAC_Setup.pdf
,
, ,
.
. [online]. . [cited 2012 Apr 1]; Available
from: URL:http://www.nhso.go.th/downloadfile/fund/
2554.pdf
.-.
Drug pricing measures for the reimbursement

Cha-oncin Sooksriwong*
Wansuda Ngam-Aroon*
Sunchai Janto*
Abstract
Background: There are many effective drug pricing systems which Thai Government should employ to solve drug pricing problems especially at the reimbursement level. This research focuses on a
comparison of budget saved by the payer after the application of different drug pricing measures at the
reimbursement level.
Methods: This was a quantitative research. The budget impact analysis modeling to estimate the
budget saved from the pricing policy implementation was employed.
Drugs belonged to the group HMG-CoA reductase inhibitor (statins) were purposive sampling to be
the sample for the budget impact analysis. They were divided into 3 groups and the sample of each group
was shown in the bracket: 1) Innovative drug with therapeutic improvement (Rosuvastatin), 2) Innovative drug with technical improvement (Amlodipine+Atorvastatin), and 3) Innovative drug with Generic
drug (Atorvastatin).
Drug pricing measures assigned for each drug groups were 1) Price Volume Agreement, 2) Value
Based Pricing, 3) Maximum Allowable cost, and 4) Reference pricing.
Results: In terms of budget saving for: 1) Innovative drug with therapeutic improvement group:
Reference Pricing measure saved more budget than Price Volume Agreement. 2) ) Innovative drug with
technical improvement group: Value Based Pricing measure saved more budget than Price Volume Agreement. 3) Innovative drug with Generic drug group: Reference Pricing measure saved more budget than
Maximum Allowable Cost.
Discussion: The magnitude of saving in each measure depends on the factors such as percentage of
drug rational use, numbers and prices of drugs available in the market, and availability of local made
drugs.
Conclusion: There are many effective drug pricing measures which can be used to reduce the reimbursement budget. The government should place the right measure to each drug to gain its most benefit.
Keywords: Drug pricing measures, reimbursement, Price Volume Agreement, Reference Pricing, Maximum Allowable Cost, Value Based Pricing.
*, *, *
*

*Faculty of Pharmacy, Mahidol University
176

HMG-CoA reductase inhibitor (statins) 3
1) (Rosuvastatin), 2)
(Amlodipine+Atorvastatin), 3) (Atorvastatin).
1) Price Volume Agreement, 2) Value Based Pricing, 3) Maximum Allowable cost, 4) Reference pricing.
1) Reference pricing Price Volume Agreement 2) Value Based
Pricing Value Based Pricing Price Volume Agreement 3) Reference
pricing Maximum Allowable Cost

:

Introduction
Performance-linked reimbursement, Reference Pricing (RP), Maximum Allowable Cost (MAC) and Value
Base Pricing (VBP).
International Price Comparison
International price comparisons for pharmaceuticals are used for 2 primary purposes; price comparisons based on a sample of products are used to
draw conclusions about differences in average price
levels, often as input to evaluation of alternative regulatory systems for drug prices. Second, cross-national
comparisons applied to individual products are used
by governments for example, Italy, Spain, The Netherlands and Canada - for setting domestic prices, usually for newly launched products. International price
comparisons limited in varies price in other country.(4)
Risk sharing by Price-Volume Agreement
Price Volume Agreement; PVA is drug policy
measures and a volume control tool. The price of a
pharmaceutical agreed between public authorities and
a manufacturer on the basis of a forecast volume of
arious countries including Thailand have faced

the increasing burden in health care expenditure mainly caused by the increase in drug spending.
Consequently, many of them established the medicine price control policy to encounter the problem.
The national health organization set prices of drug to
be reimbursed. However, Thailand has not yet developed any drug pricing control measures and policies.
Drugs utilized under the Civil Servants Medical Benefit Scheme (CSMBS) are reimbursed by The Comptroller Generals Department of The Ministry of Finance. Major drug pricing problems found at the reimbursement level in Thailand were: variation of purchasing and selling prices of same drug trade names
among hospitals, ineffective drug price negotiation
for high cost- monopoly innovator drugs(1), and high
consumption of expensive innovator drugs.(2,3)
There are many effective drug pricing systems
such as International Price Comparison, Risk sharing
by Price-Volume Agreement (PVA), Risk sharing by
.-.
sales. If the actual sales volume exceeds the forecast,

the price of the pharmaceutical is usually reviewed
downwards. Particularly useful in situations where unit
prices are higher than comparators and there is potential for high prescription volumes, or when there
is significant uncertainty about the estimated volumes.(5)
Risk sharing by Performance -linked Reimbursement
This approach is used when a manufacturer
agrees to refund the cost of ineffective treatment to
the payer. They assume their drug is having benefit
outcome on the patients. The payer will pay for only
drug that improves health outcome. Risk-sharing is
the common practice of tying pharmaceutical reimbursement or recommendation for adoption to health
outcome. It can be called in many different ways based
on the country in which they are negotiated and/or
the companies that undertake them. The most common are value-based pricing, conditional coverage,
pay-for-outcomes and performance based pricing. Two
factors that encourage the use of risk-sharing are pharmaceutical cost and pharmaceutical quality.(6)
Reference Pricing
Reference Pricing; RP is to set fixed reimbursement limits for products assigned to the same
group. In principle, products that treat the same medical condition are clustered together and a judgment
made as to what a fair common price would be for all
products in the cluster for a typical patient. RP is not
strictly a price control mechanism as the pharmaceutical manufacturer is free to set any price for their
product. It can intensify price competition among drug
in the same cluster. This is an advantage of RP. The
purpose of reference pricing of fixed reimbursement

levels is to limit the rise in pharmaceutical expenditure by setting a limit on the price that health care
payers will fully reimburse and requiring patients to
pay any excess of the price of the prescribed drug
over the reference price.(7)
Other issues may also be involved, it is anticipated to increase patient and physician awareness of the prescribed drugs price and possibly result in the patient being switched to a drug listed at
the reference price. If switching occurs, then a convergence of drugs in the same category to the reference price generally follows. RP is one of the few
available policies likely to be effective at directing
prescriber behavior towards the latter approach. Because RP does not influence the factors which relate
to increases in the volume of drugs used, it may produce at best, a temporary interruption in the rate of
increase of drug prices. In addition, RP forces manufacturers of branded products to choose between two
strategies: 1) to reduce prices to bring them in line
with the reference price, or 2) to maintain prices above
the reference price therefore, capture a brand-premium for its efforts in marketing and sales and eventually for real differences in quality.
A comprehensive review of the publish literature of reference pricing by Lopez-Casasnovas and
Puig-Junoy(7) showed that the prices of products covered by reference pricing tended to decrease, leading
to reductions in third-party pharmaceutical expenditure.
Maximum Allowable Cost
Maximum Allowable Cost; MAC is method
for establishes maximum reimbursement amounts for
178
equivalent groups of multiple-source generic drugs.(8)

The government has the flexibility to establish their
own payment ceilings for multiple source drugs, so
long as they do not exceed the federal payment ceiling for Federal Upper Limit (FUL) drugs. Slightly over
half the states have taken advantage of this cost containment tool, which would enable them to limit their
liability with regard to drug pricing.
The federal government has accepted several
state options for calculating the reimbursement to
pharmacies for prescriptions for patients. Most use a
formula based on the Average Wholesale Price (AWP)
reported for each drug to determine reimbursement
to pharmacies.
However, when multiple generic equivalent drugs
are available, states have the option of using Maximum Allowable Cost (MAC) to set a cap on payment
for brand or generic versions of the same drug. States
may establish their own MAC to use for reimbursement to pharmacies. Under the MAC formula, states
establish a single price for each generic regardless of
the manufacturer of the generic.(9)
Value Base Pricing
Value-based pricing is a method of pricing products in which companies first try to determine how
much the products are worth to their customers. The
goal is to avoid setting prices that are either too high
for customers or lower than they would be willing to
pay if they knew what kind of benefits they could get
by using a product.(10)
The limitations relating to the practical application of VBP for medicines.(10) They include:
1) A lack of evaluation of the additional health
related benefits of items such as new medicines for
conditions like.
2) The government is also not presently
charged with evaluating the long term external benefits that will in time be generating as a result of, for
instance, an improved understanding of cancer
genomics and/or the provision of high quality employment in the pharmaceutical sector
3) A lack of between best practice developments and the publication of supportive evidence.
Objectives of this study

To compare budget saved by the payer after the
application of different drug pricing measures at the
reimbursement level.
Methods
Research design
This was a quantitative research. The budget
impact analysis modeling to estimate the budget saved
from the pricing policy implementation was employed.
Sampling procedure
Drugs belonged to the group HMG-CoA reductase inhibitor (statins) were purposive sampling to be
the sample for the budget impact analysis. They were
divided into 3 groups and the sample of each group
was shown in the bracket:
1. Innovative drug with therapeutic improvement (Rosuvastatin),
2. Innovative drug with technical improvement (Amlodipine+Atorvastatin),
3. Innovative drug with Generic drug
(Atorvastatin).
Drug pricing measures assigned for each drug
.-.
groups were 1) Price Volume Agreement, 2) Value

Based Pricing, 3) Maximum Allowable cost, and 4)
Reference pricing
PVA measure, the reimbursed price were compare percent of benefit rebate to third party payer.
The rational were set at 70 percent, then the exceeding 30% of consumption will be reimbursed less; at
50% of original price.
VBP measures, the reimbursed price were compare the price of fixed-dose combination with single
original price and single local made price. The benefit were refund at percentage difference of price into
government.
MAC measures, The reimbursed price were calculate multiple by rate MAC price. The first lowest
price were multiplied with 110%. The second lowest
prices were multiplied by 106%. The price were selected on the higher of the two MAC rates price
RP measure, the reimbursement of original drug
price instead with local made drug price in same
pharmacology. The drug price were calculated from
median price divides with Define Daily Dose; DDD of
local made drug price.
Data collection
The amount and value of imported drugs in 2010
were collected from the Food and Drug databases.
Their drug utilization data in 2010 were retrieved from
one teaching hospital databases; data variables included the drug name, strength, dosage form, and
drug cost and charge, volume and value of drug utilization according to types of payment scheme as
Civil Servants Medical Benefit Scheme (CSMBS),
Universals Coverage (UC), Social Security System
(SSS), and Self pay.
Data analysis
An Excel model was constructed for the Budget Impact Analysis in terms of budget saved by the payer
after the application of different drug pricing measures at the reimbursement level. The measure that
saved most would be recommended.
This price per tablet is available on the website
of Center of Essential Information for All Health Officers (DMSIC), http://dmsic.moph/price/price1.php. Only
the drugs utilized by CSMBS patients are reimbursed
by the Ministry of Finance, so the number of CSMBS
patients who used Rosuvastatin, Amlodipine+
Atorvastatin, and Atorvastatin during the year 2010
at a teaching hospital were retrieved and calculated
as percentage of total consumption of that drug. This
percentage was multiplied to total imported or manufactured volume, as retrieved data from the FDA, to
be an approximate volume of the national consumption.
Results
The considering of Outpatient drug utilization
and expenditure of Civil Servant Medical Benefit
Scheme, CSMBS found that total drug utilization
percentage all drug groups in CSMBS scheme show
that atorvastatin (76.87% or 2902.04 M.baht), and
rosuvastatin (77.69% or 1144.41 M.baht) of group were
drug with the highest drug expenditure percentage
in HMG co A inhibitor group
1. Pricing measures for innovative drugs with
therapeutic improvement.
Rosuvastatin was selected as the sample. In
the year 2010, Rosuvastatin was imported 1,473 M.
baht, or 33,869,052 DDD (43.49 baht/DDD). Consump-
180
tion of this drug by CSMBS patients at a teaching

hospital was 77.69%; so approximately 1144.41 M.baht
were consumed by CSMBS patients at the national
level which will be reimbursed. Two pricing measures will be applied as:
1.1 Risk sharing by Price-Volume agreement.
The volume of drug used rationally will be fully reimbursed. The exceeding consumption will be reimbursed at a downward negotiated price. Lets set the
example of Rosuvastatins rational use at 70%, then
the exceeding 30% of consumption will be reimbursed
less; at 50% of original price. Therefore 30% consumption or 343.32 M.baht will be reimbursed at 171.16
M.baht instead of 343.32 M.baht. So the government
will save 171.66 M.baht or 15 % (171.66 M.baht 100/
1144.41 M.baht.) by Price-Volume agreement. But if
the government decides not to reimburse for the irrational use portion, then 343.32 M.baht will be saved.
1.2 Reference pricing
By this measure Rosuvastatin will be reimbursed at the price of lowest generic drug in the
same therapeutic group which should be Atorvastatin.
The price of Atorvastatin is 17.79 baht./DDD compared to Rosuvastatin at 43.49 baht/DDD. Then
Rosuvastatin will be reimbursed at 17.79 baht./DDD
or saved by 59.09%. When this figured is calculated
as national consumption, it will save 676.28 M.baht.
technical improvement.
Amlodipine+Atorvastatin was selected as the
sample. In the year 2010, Amlodipine+Atorvastatin
was imported 290.0 M.baht, or 3,678,150 DDD (79.0
baht/DDD). Consumption of this drug by CSMBS patients at a teaching hospital was 79.5%; so approxi-
mately 230.48 M.baht were consumed by CSMBS

patients at the national level which will be reimbursed.
Two pricing measures will be applied as:
2.1 Risk sharing by Price-Volume agreement.
The volume of drug used rationally will be fully reimbursed. The exceeding consumption will be reimbursed at a downward negotiated price. Lets set the
example of Amlodipine+Atorvastatin rational use at
70%, then the exceeding 30% of consumption will be
reimbursed less; at 50% of original price. Therefore
30% consumption or 69.17 M.baht will be reimbursed
at 34.58 M.baht instead of 69.17 M.baht. So the government will save 34.58 M.baht or 15% (34.58 M.baht
100/230.55 M.baht.) by Price-Volume agreement.
2.2 Value Based pricing When 2 singular
drugs are reformulation as a fixed-combination drug
and registered as an innovative drug but shows no
therapeutic improvement when compared with the
co-administration of each single agent, the price of
this fixed-combination drug should not exceed the
summation of each single agent. In this example fixed
combination of Amlodipine 10 mg +Atorvastatin 40
mg are priced 85.00 baht(11), while single Amlodipine
10 mg is 1.41 baht. and Atorvastatin 40 mg is 37.23
baht from the website of DMSIC. The price of this
fixed combination should not be more than 38.64 baht.
And the therapeutic efficacy of the combination drug
is not better than co-administration of each single
agent.(12,13) Thus the reimbursement price should be
38.64 baht. not 85.00 baht., and the government will
save 46.36 baht. per tablet or 54.54%
generic drugs
When innovative drugs were off-patent, im-
.-.
ported an d local made generics would enter the

market. This part illustrates the Reference Pricing
measure and Maximum Allowable Cost pricing measures for reimbursement. Atorvastatin 40 mg is the
example of this group. In the year 2010 Atorvastatin
40 mg was imported 728.16 M.baht. or 12,161,720 tablet
(59.87 baht./tablet), 76.87% were consumed by CSMBS
patients, or approximately 559.71 M.baht at the national level which will be reimbursed. Two pricing
measures will be applied as:
3.1 Reference Pricing: By this measure innovative Atorvastatin 40 mg will be reimbursed at
the price of lowest generic drug in the same therapeutic group which should be Simvastatin 40 mg.
The price of Simvastatin 40 mg is 1.13 Baht./tablet

compared to Atorvastatin 40 mg at 59.87 baht/tablet.
Then Atorvastatin will be reimbursed at 1.13 baht. or
saved by 58.74 baht./tablet or 98.11%. When this figured is calculated as national consumption, it will
save 549.13 M.baht.
3.2 Maximum Allowable Cost (MAC): Average prices for 3 available brands of Atorvastatin 40
mg were 50.29 baht., 37.23 baht., and 29.00 baht.;
calculated MAC was 39.46 baht./tablet.* As compared to average imported Atorvastatin 40 mg at 59.87
baht/tablet. Then Atorvastatin 40 mg will be reimbursed at 39.46 baht/tablet or saved by 20.41 baht./
tablet, or 34.09%. When this figured is calculated as
Table 1 Comparison of value (Million baht.) and % saved for the government by application of each pricing measure at the
reimbursement.
1.Innovative drugs
with therapeutic
improvement
Sample
Rosuvastatin
Value imported (M.baht.)
1,473.00
% consumed by CSMBS
77.69
Value consumed by CSMBS
1,144.41
Value, M.baht. (% saved) for the government by each pricing measure
- Risk sharing by Price-Volume agreement
171.16
(15%)
- Value Based pricing
- Reference Pricing
Drug classification
2. Innovative drugs
with technical
improvement
Amlodipine+Atorvastatin
290.00
79.50
230.55
34.58
(15%)
125.64
(54.54%)
675.20
(59.09%)
- Maximum Allowable Cost
*Calculation: First MAC rate price

= first lower price 1.1
= 29 1.1
= 31.9 baht.
Second MAC rate price
= second lower price 1.06 = 37.236 1.06
= 39.46 baht.
So the reimburse price by MAC rate will be 39.46 baht.; because this rate is higher than the first and second lower prices.
182
3. Innovative
drugs with
generic drugs
Atorvastatin 40 mg
728.16
76.87
559.71
549.13
(98.11 %)
190.81
(34.09%)
national consumption, it will save 190.81 M.baht.

Table 1 shows the summary result of each measure. It was found that the Reference Pricing measure is the most budget saving at the reimbursement
level.
vide reasonable reimbursed prices for the manufactures of generic drugs because it is not based on the
lowest price in the market.
The magnitude of saving in each measure depends on the factors such as percentage of drug rational use, numbers and prices of drugs available in
the market, and availability of local made drugs.
In the case of Rosuvastatin, the budget saved
from RP is higher than PVA because we set the pricing model as 70% rational use and reimbursed 50% of
those with irrational use. If the percentage of rational
use was 10% and no reimbursement for irrational use,
then the amount of budget saved would be much
higher. For RP, the prices of generic reference drugs
are very cheap, thus the budget saved is high. The
application of RP measure may cause patients to copay if they want to use original drugs or premium
generic drugs. For fixed combination drug like
Amlodipine+Atorvastatin it is not possible to use RP
measure but Value Based pricing is preferable.
Discussion
It is impossible to point out which measure will
best for each drug because of different pattern of drug
utilization and drug prices in the market. When compared between Price-Volume agreement (PVA) and
Reference Pricing (RP), the magnitude of budget saved
by PVA depends on the percentage of rational use
and the percentage of price reimbursed for drug used
irrationally; while the magnitude of budget saved for
RP depends on the prices of generic drugs in the
market. For PVA, if the percentage of irrational use is
very high then the budget saved from price reduction of irrational use drug will be high; and if the
percent reimbursed of irrational use drug is low then
the budget saved will be high. For RP, if the price of
a drug used as reference is not much cheaper than
the original one then the budget saved will not be
much. There was not any study revealed the percentage of drug rational use, so this rate used in this
study was set up. Application of the PVA measures
needs a reliable rate of drug rational use.
Regarding the Value Based pricing, it is important to keep in mind about the efficacy of drugs and
the prices, this measure should be used when there
are enough document to prove the efficacy of single
drug and combined drugs.
When there are many brands in the market the
Maximum Allowable Cost (MAC) measure will pro-
Limitation of study
There might be some other effective pricing measures which are not mentioned here, so they should
be thoroughly explored before selecting an appropriate one.
Conclusion and recommendations

In terms of budget saving for: 1) Innovative drug
with therapeutic improvement group: The Reference
Pricing measure saved more budget than Price Volume Agreement. 2) Innovative drug with technical
improvement group: The Value Based Pricing measure saved more budget than Price Volume Agree-
.-.
ment. 3) Innovative drug with Generic drug group:

The Reference Pricing measure saved more budget
than Maximum Allowable Cost.
This study shows that there are many effective
drug pricing measures which can be used to reduce
the governments reimbursement budget. The government should place the right measure to each drug
to gain its most benefit. There should be an office
that provides information regarding drug use pattern
and market pattern for the organization to use as input for the reimbursement purpose.
4.
5.
6.
7.
8.
Acknowledgements
We would like to thank Health Systems Research
Institute, who granted this study; and express much
appreciation to all experts who provided valuable
guidance and suggestion.
10.
References
11.
9.
1. , .
. 2537;3:726-37.
2. Yupapun Munkratok, Vithaya Kulsomboon, Yupadee Sirisinsuk.
Expenditures on High-cost Drugs and the Difference in Their Use
under Various Health Insurance Schemes in a Regional Hospital in
North-Eastern Thailand.Journal of Health Systems Research 2009;
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Norbert Wilk. Price-Volume Agreements prospects for Poland.
[Cited 2011 Sep 20]. Available from: URL: www.mz.gov.pl/
wwwfiles/ma_struktura/zal6_polska_en_19112007.ppt
Craig AH, John G, Rebecca SC, Abdulkadir K. A literature review
of risk-sharing agreements. Korean Academy of Managed Care
Pharmacy 2010;2:1-9.
Lopez-Casasnovas G, Puig-Junoy J. Review of the literature on
reference pricing. Health Policy 2000;54:87-123.
Department of Medical Assistance Services. Maximum Allowable
Cost Program Reimbursement Methodology for Generic Drugs.
[cited 2011 Sep 15].Available from:URL: www.dmas.virginia.gov/
downloads/studies_reports/2004-RD198.pdf
Generic pharmaceutical association, Maximum Allowable Cost.
[Cited 2011 Sep 12].Available from:URL:http://www.gphaonline.org/
resources/2009/maximum-allowable-cost-mac
David Taylor. Implementing Value Based Pricing for Medicines
An introduction [Cited 2011 December 2]. Available from: URL:
http://www.fundsis.org/docs_act/164_Implementing-Value-Based-Pricing-for-Medicines-in-the-UK.pdf
. [Cited 2011 Sep
12].Available from:URL:http://www.si.mahidol.ac.th/th/department/
pediatrics/admin/news_files/109_2_1.pdf
Bangalore S, Kamalakkannan G, ParkarS, and Messerli FH. FixedDose Combinations Improve Medication Compliance: A MetaAnalysis. Am J Med 2003;120:713-9.
McKeage K, Siddiqui M, Asif A. Amlodipine/atorvastatin fixeddose combination: a review of its use in the prevention of cardiovascular disease and in the treatment of hypertension and
dyslipidemia. Am J Cardiovasc Drugs 2008;851-67.
.-.
Determination of 2010 Reimbursed

Drug Price and Its Budget Impact
in Public Hospitals in Thailand
Petcharat Pongcharoensuk*
Angkana Saengnapakas
Oraluck Pattanaprateep
Abstract
Total drug expenditure for Civil Servant Medical Benefit Scheme (CSMBS) has rapidly increased.
Reference pricing (RP, or maximum reimbursable limit) for drugs is proposed as a means to control drug
expenditure. The objectives of this study were to determine the RP of five high expenditure drug groups
and estimate the budget impact of RP implementation. Prescription records of 29 public hospitals in 2010
were collected. Drug utilization and several RPs of each drug product were determined. Then, overall
budget impact was determined for RP under three different scenarios.
Results showed that there were 1.7 million prescriptions, accounted for 2.5 billion baht. By drug
group, total number of prescriptions were 39.96%, 26.25%, 16.57%, 13.68% and 3.55% while total expenditures were 44.65%, 20.43%, 20.59%, 4.47% and 9.85% for statins, Proton Pump Inhibitors (PPI), Angiotensin Receptor Blockers (ARB), Angiotensin-Converting Enzyme Inhibitors (ACEI), and Bisphosphonates
(BIS) respectively. Brand name drugs accounted for 94.8% of expenditures but 50.6% of prescriptions. If
RP was implemented, the highest savings (50.39% of expenditure) would be from pharmacological substitution (eg. price of Atorvastatin is equal to median price of generic Simvastatin). Generic substitution
(median price of generic for brand Simvastatin) would result in 20.56% savings while 15.91%-17.26%
savings would be achieved if brand drugs were reimbursed at cost plus 50 or 30 baht dispensing fee per
item respectively.
Use of high price, brand drugs has burdened the overall drug expenditure of government hospitals.
Reference pricing would encourage generic drug use and thus, help not only to control overall expenditure, but also strengthen the local manufacturing drug industry.
Keywords: reference pricing, drug expenditure, civil servant, government hospitals

*, ,
* , ,

()
*Faculty of Pharmacy, Mahidol University
Samut Prakan Hospital
.-.

. ,
., ., ., . . .,
., ., . . Statins, Proton Pump Inhibitors (PPI), Angiotensin
Receptor Blockers (ARB), Angiotensin-Converting Enzyme Inhibitors (ACEI), Bisphosphonates (BIS)
. .
( . ) (
Simvastatin Atorvastatin)
. . - .
(Dispensing fee)

: , , ,
Introduction
following drug groups: Angiotensin II Receptor Blocker

(ARBs), single-source statins, clopidogrel, single-source
Proton Pump Inhibitors (PPIs), Bisphosphonates
and Coxibs had a major impact on overall drug expenditure.(3)
RP is one measure to control drug expenditure(4,5)
in several European countries. RP is a maximum reimbursement limit for drug products classified in the
same group. Products that treat the same medical
condition are clustered together and a calculation is
made as a common reimbursed price for all products
in the cluster, eg. price of generic Simvastatin for all
other statins. RP is not a direct price control mechanism as the pharmaceutical manufacturer is able to
set any price for their drug products. However, RP
would encourage price competition among drugs in
the same cluster. The purpose of reference pricing of
fixed reimbursement levels is to control the rise in
pharmaceutical expenditure by setting a limit on the
harmaceutical expenditure is one of the major

factors behind the growth of total health care
expenditure. In Thailand, total health expenditure (for
65 million people) was 389,625 million baht or 4.3% of
Gross Domestic Product (GDP) in 2009.(1) However,
total health expenditure for 5-million people under
Civil Servant Medical Benefit Scheme (CSMBS) had
been increasing rapidly, from about 30,000 million baht
in year 2005 to more than 62,000 million baht in 2010.(2)
It is more than doubled in just five years. In fiscal
year 2009, based on the 10-month prescription records
from 34 public hospitals, there was a total of 16.6
million prescriptions, accounting for 15 billion baht
expenditure, 66% of which was from 34% utilization
of Non-Essential Drug (NED). Among the NEDs, singlesource drugs are the contributing factor for the increase in drug expenditure at government hospitals.
This study by Limwattananon et al. showed that the
186
price that health insurance payers will fully reimburse

providers. A comprehensive review of reference-pricing literature by Lopez-Casasnovas and Puig-Junoy(4)
showed that prices of products covered by reference
pricing tended to decrease, leading to reductions in
third-party pharmaceutical expenditure. A reduction
in drug prices was found ranging from 11% to 26%(5)
for different reference drug groups. Price reduction
occurred in Germany after patients were switched to
drugs listed under the reference price, and thus, avoid
additional cost of co-payment.(6)
In Canada, reduction in expenditure for drug in
the reference groups (anti-angina, Non-steroid antiinflammatory, H2-receptor antagonist, ACEI) was found
ranging from -5% to 50%.(7-13) RP also affected drug
utilization, Aaserud et al. reported a 60% and 196%
increase in use of prescriptions under reference price
during the transition period and following the implementation of the RP, compared to the period before
the implementation.(5) With the implementation of
RP in EU countries, it is expected to increase patient
and physician awareness of the prescribed drugs price
and increase the probability of the patient being
switched to a drug listed under the reference price.(4,6)
With the rapid increase in drug expenditures
under the health scheme for government employees
as mentioned above, reference price was deemed a
measure to reduce the rapid growth rate as there is
no RP scheme ever initiated in Thailand. The objective of this study were to determine the RP of five
high expenditure drug groups (two anti-hypertensives,
anti-ulcer, Bisphosphonate and anti-hyperlipidemia
drugs) and estimate the budget impact of RP implementation in public hospitals.
METERIALS AND METHODS

Design
This is retrospective study of drug prices from
hospital database.
Data source
There are three sources of drug price data. Two
databases are retail drug price from prescription utilization records, one from the National Health Security Office (1 September 2009 to 1 August 2010) and
another from 29 public hospitals of CSMBS (1 October 2009 to 31 July 2010). The third is drug purchased
cost gathered from Drug and Medical Supplies Information Center (DMSIC, http://dmsic.moph/price/
price1.php), an information center under the Ministry
of Public Health. At its website, purchased price of
drugs that the hospitals reported to DMSIC were available for download.
Study population
Population are prescriptions for oral dosage forms
of anti-hyperlipidemia (Statin group), Bisphosphonate,
Angiotensin II Receptor Blocker (ARB), Angiotensin
Converting Enzyme Inhibitor (ACEI), and Proton Pump
Inhibitor (PPI). They are drug groups that accounted
for a high proportion of the hospitals expenditure
under CSMBS.(3)
Data collection
Data retrieval
Data were retrieved in the format of Microsoft
Excel 2007 from the two utilization databases. Only
oral forms of the five drug groups were identified using the Anatomical Therapeutic Chemical (ATC)
codes; A02BC for PPI, C09A for ACEI, C09CA for ARB,
.-.
C10AA for statins, and M05BA for BIS. Data of prescriptions records consist of hospital code, standard
code, trade name, chemical name, dosage form,
strength, quantity of drug dispensed and drug retail
price per unit (tablet or capsule). For drug cost, the
following data are retrieved from DMSICs website:
drug name (chemical name), trade name, strength,
dosage form, drug company, minimum price, mode,
median, and the time period of price calculation. An
addition code was initiated to show the source of
drug products as:
O Single source (S), a prototype drug with
single manufacturer,
O Original (O), a prototype drug with generic
available in Thailand,
O Imported (I) generics, and
O Locally (L)manufactured generics.
mined were prices per defined daily dose (DDD) of

each drug product, to be used as the unit reimbursable price of substitution among different drugs in
the same cluster. Second is determination of cost
savings under different scenarios of RP that is explained below. There are three scenarios of RP.
Scenario I
There is no generic substitution and RP is divided into purchased price or drug cost plus dispensing fee. Cost of drugs was from DMSIC data. However, cost data were not available for some singlesource drugs. In these cases, drug cost was determined at 80% of retail price. Dispensing fee covers
the administrative cost of drug distribution, purchasing and inventory control, as well as some patient
care costs incurred by the pharmacy.(14) There are
two dispensing fees, 30 baht and 50 baht per drug
item, the former is based the 30-baht for Universal
Coverage Scheme while the latter is the actual fee for
pharmacy service at government hospitals. In this
scenario, the fee is set per drug item, not per prescription.
Scenario II
There is generic substitution (of brand name with
generic equivalent product) based on DDD. RP is set
as baht/DDD of each drug product. The median price
per DDD of generic (L) is the reimbursed drug price
for original (O) and imported (I) drugs. Minimum price
is set as reimbursable limit for single-source (S) drugs.
Scenario III
Pharmacological substitution (eg. Atorvastatin is
substituted by generic Simvastatin) was used in this
scenario. Pharmacological substitution is referenced
from Franciscan Health System, March 11, 2005.(15)
Data validation
Retrieved data in Microsoft Excel 2007 data format were checked for consistency. These data were
then verified for completeness and accuracy. Duplicated record, which may occur from human key-in
error were eliminated. Other errors from different hospitals data format and/or retrieval queries were then
modified into correct ones.
Data analysis
Data were analyzed by Stata version 11.0 and
Microsoft Excel 2007. Data analysis was divided into
two parts. First, descriptive statistics of outpatient
drug utilization and unit retail drug price (baht, mean
and standard deviation, min, max, p25, p50 and p75)
were determined for each drug product. Also deter-
188
As the second scenario, the median price per DDD of

generic is used as reimbursed price of original (O)
and single-source (S) drugs.
In scenario II and III, only 80% of total prescriptions were substituted. The remaining 20% will not
be substituted for reasons such as patient preference
or allergic to generics or under physician recommendations.
among ACEI, PPI, and Statin, but only 14.90% and

1.10% for ARB and BIS respectively, of which single
source (S) were the majority of drug use, 49%, and
81.4% respectively.
Cost saving of reimbursed price
For reimbursed drug price in three scenarios, it
was found that the cost saving in Scenario I (DF=30),
I (DF=50), II and III was 17.26%, 15.91%, 20.55% and
50.39%, respectively. Pharmacological substitution
(Scenario III) had the highest percentage of cost saving (Table 2). Across drug groups, Scenario I and III
show more consistency in percent saving; whereas
there were wide ranges of saving (0.09% for BIS to
31.01% for ARB) in Scenario II.
Results
Outpatient drug utilization and expenditure
There were a total of 1,696,976 prescriptions of
CSMBS patients for the five drug groups, accounting
for 2,498.66 billion baht expenditure (Table 1). It was
shown that use of generic prescriptions (L and I,
49.40%) was approximately the same as brand names
(O and S, 50.60%), however, total brand drug expenditure was 94.90%. In other words, brand name drugs
were 20 times as expensive as generics.
By therapeutic classification, there were 39.96%,
26.25%, 16.57%, 13.68% and 3.55%, of total prescriptions, but 44.65%, 20.43%, 20.59%, 4.47%, and 9.85%
of total expenditure for Statin, PPI, ARB, ACEI and
BIS respectively (Table 2). The percentages of generic drug (L and I) use were 71.40%, 60.50%, 53.20%
Discussions
Scenario I (drug cost + dispensing fee) had the
lowest level of saving but with the advantage of easy
implementation. There was no substitution, so patients get the drug as prescribed by physicians, therefore, treatment of patient is not affected. It is easy for
implementation since it would not interfere with the
physician-patient relationship. In addition, reimbursement based on drug cost would discourage the use of
original and single-source drug because the profit
Table 1 Drug utilization of civil servants during 1 October 2009 to 31 July 2010 by type of manufacturers
Type
L
I
O
S
Total
Total Prescriptions
836,519
1,912
344,175
514,370
1,696,976
Total Expenditure, baht
49.29
0.11
20.28
30.31
100.0
122,563,884
4,682,753
933,493,012
1,437,923,355
2,498,663,003
4.91
0.19
37.35
57.55
100.0
L=generic drug, I=imported generic, O=original drug, S=single source drug
.-.
Table 2 Expenditure and cost saving of each drug groups when reimbursed drug price was implemented under three scenarios
Scenario/Expenditure
Total prescriptions
% Total prescription
% Generic prescription
Expenditure (baht)
% Expenditure
ACEI
ARB
BIS
PPI
Statin
Total
232,065
13.68
71.40
111,676,845
4.47
281,154
16.57
14.90
514,582,077
20.59
60,175
3.55
1.10
246,131,383
9.85
445,434
26.25
60.50
510,516,399
20.43
678,148
1,696,976
39.96
100.00
53.20
49.40
1,115,756,299 2,498,663,003
44.65
100.00
Scenario I (Drug cost + Dispensing fee)

RP Drug cost (baht)
30 baht DF
Total DF (30 baht)
Cost saving (baht)
% Cost saving
50 baht DF
Total DF (50 baht)
Cost saving
% Cost saving
78,450,450
430,870,951
215,110,018
404,419,982
887,918,522
2,016,769,923
6,961,950
26,264,445
23.52
8,434,620
75,276,506
14.63
1,805,250
29,216,115
11.87
13,363,202
93,113,236
18.24
20,344,410
207,493,363
18.60
50,909,250
431,363,664
17.26
11,603,250
21,623,145
19.36
14,057,700
69,653,426
13.54
3,008,750
28,012,615
11.38
22,271,700
84,204,556
16.49
33,907,350
193,930,431
17.38
84,848,750
397,424,172
15.91
Scenario II (Generic substitution)

RP expenditure (baht)
80% substitution
Cost saving (baht)
Cost saving (80% substitution)
% Cost saving
89,522,789
354,994,790
230,313,010
510,072,859
800,199,716
1,985,103,163
22,154,057
19.84
159,587,286
31.01
15,818,373
6.43
443,540
0.09
315,556,584
28.28
513,559,840
20.55
Scenario III (Pharmacologic substitution)

RP expenditure (baht)
80% substitution
89,522,789
Cost saving (baht)
Cost saving (80% substitution)
22,154,057
% Cost saving
19.84
310,408,226
154,969,242
343,107,489
341,505,069
1,239,512,814
204,173,851
39.68
91,162,141
37.04
167,408,911
32.79
774,251,230
69.39
1,259,150,190
50.39
margin is not based on drug cost. The present reimbursement of cost + % margin method by the government provides incentives for use of brand name drugs
since the providers would get higher drug margin,
when compared with generics. In other words, with
the same percentage margin, use of high-cost drug
would earn higher margin for the providers. Dispens-
ing fee would solve this problem. Another advantage

of dispensing fee is to compensate the pharmacist
for providing professional services of dispensing drug
products. It covers all the administrative costs of purchasing, stocking and distribution of medication to
patients. Additional cost of professional services or a
profit margin could be added to this fee.
190
However, the data may not reflect the actual

drug cost. If the hospital reports drug cost that exclude price discounts from promotions to DMSIC, drug
cost would be overestimated. As a result, the reimbursed price is high and less money saving. Another
limitation of the DMSIC drug cost is the completeness of data. DMSIC data report all drug cost in the
national essential drug list plus some of Non-essential drugs. Therefore, estimation of other Non-essential drug costs were determined by 20% reduction
from retail prices. Another limitation of this scenario
is that different dispensing fees for different size of
hospitals are needed to reflect the actual administrative costs for providing other professional services
such as counseling or patient drug monitoring.
Generic substitution by the median price/DDD
of generic for same brand name is set as reimbursed
price for Scenario II. The number of generic products
in the drug group is an important factor. ACEI, ARB
and Statin would save 20-31% of total expenditure
since there are several products with generics,
whereas PPI and BIS would save much less since
there is only one generic but many single-source drugs
in each group. The percentage of cost saving will be
greater if the number of generic drugs in each group
are increased. Use of generic drugs would help the
local manufacturing industry.
Pharmacological substitution by the median
price/DDD of generics is set as the reimbursed limit
in Scenario III. The cost saving of ACEI group is the
same as scenario II, because there are several generic drugs in this group and drug utilization of generic drugs are already high. Statin group had the
highest cost saving in this scenario (69.39%) because
generic Simvastatin can substitute for four of the five

drugs (Atorvastatin, Fluvastatin, Pravastatin and
Rosuvastatin). When compared with ARB and PPI,
ability to substitute is low since there is one generic
in each group, only Irbesartan is substituted by generic Losartan in the former and Omeprazole can substitute esomeprazole and pantoprazole in the latter
group. There are other single-source drugs with no
therapeutic substitution. For BIS, even though ability
to substitute is high, but price of the only imported
Alendronate is also high, therefore, saving is low
(37.04).
Pharmacological substitution is more complicated
than generic substitution. It requires clinical evidence
for its therapeutic interchangeability among different
generics in the same drug cluster, before it can be
substituted across different products. Therefore, acceptability among physicians may be low since it
would interfere with physicians prescribing preference.
This study shows that the original and single
source drug prices are expensive. In addition to the
determination of a common reimbursed drug price,
there are other cost controls methods that can be
used in conjunction with RP such as price negotiation and international price comparison. These measures could lower the purchased price of drugs.
Furthermore, if RP measure is to be sustainable in the long-run, there should be other supportive
mechanism for implementation, such as a drug information center to maintain an accurate and up-todate drug cost or price as well as drug utilization for
reimbursement, or an incentive for health care providers to prescribe drugs under the reference price.
.-.
6. Pavcnik N. Do pharmaceutical prices respond to potential patient

out-of-pocket expenses? Journal of Economics 2002;33:469-87.
7. Grootendorst PV, Marshall JK, Holbrook AM, Dolovich LR, OBrien
BJ, Levy AR. Impact of reference-based pricing of nitrates on the
use and costs of anti-anginal drugs. CMAJ 2001;165:1011-9.
8. Grootendorst PV, Marshall JK, Holbrook AM, Dolovich LR, OBrien
BJ, Levy AR. The impact of reference pricing of nonsteroidal
anti-inflammatory agents on the use and costs of analgesic drugs.
Health Services Research 2005;40:1297-317.
9. Marshall JK, Grootendorst PV, OBrien BJ, Dolovich LR, Holbrook
AM, Levy AR. Impact of reference-based pricing for histamine-2
receptor antagonists and restricted access for proton pump inhibitors in British Columbia. CMAJ 2002;166:1655-62.
10. Schneeweiss S, Dormuth C, Grootendorst P, Soumerai SB, Maclure
M. Net health plan savings from reference pricing for angiotensinconverting enzyme inhibitors in elderly British Columbia residents. Med Care 2004;42:653-60.
11. Schneeweiss S, Soumerai SB, Glynn RJ, Maclure M, Dormuth C,
Walker AM. Impact of reference-based pricing for angiotensinconverting enzyme inhibitors on drug utilization. CMAJ 2002;
166:737-45.
12. Schneeweiss S, Soumerai SB, Maclure M, Dormuth C, Walker
AM, Glynn RJ. Clinical and economic consequences of reference
pricing for dihydropyridine calcium channel blockers. Clin Pharmacol
Ther 2003;74:388-400.
13. Schneeweiss S, Walker AM, Glynn RJ, Maclure M, Dormuth C,
Soumerai SB. Outcomes of reference pricing for angiotensin-converting-enzyme inhibitors. N Engl J Med 2002;346:822-9.
14. United States Government Accountability Office. Medicare: appropriate dispensing fee needed for suppliers of inhalation therapy
drugs. (Access April 24, 2012 at: http://www.gao.gov/new.items/
d0572.pdf.
15. Franciscan Health System. THERAPEUTIC INTERCHANGE. (Access Dec 15, 2010 at: http://www.ashp.org/s_ashp/docs/files/
TherapeuticInterchange.pdf).
The health care providers that promote generic use

under RP should be compensated financially so that
it would not negatively affect the financial status of
the hospitals.
Conclusion
Use of brand name, expensive drugs has burdened the overall expenditures of civil servants of
government hospitals in Thailand. Reference price
could be a means for cost-containment and it can be
done in different ways. RP would encourage generic
drug use and thus, help strengthen the local manufacturing drug industry.
References
1. Thailand-National expenditure on health (Baht). (Access July 25,
2011 at: http://www.who.int/nha/country/tha.pdf).
2. (TDRI). .
2553.
3. , ,
.

.
; 2552.
4. Lopez-Casasnovas G, Puig-Junoy J. Review of the literature on
reference pricing. Health Policy 2000;54:87-123.
5. Aaserud M, Dahlgren AT, Kosters JP, Oxman AD, Ramsay C,
Sturm H. Pharmaceutical policies: effects of reference pricing,
other pricing, and purchasing policies. Cochrane Database Syst
Rev 2006(2):CD005979.
192
.-.
*

*
*

*
: , , , , ,
,
Abstract
Hematopoietic stem cell transplantation in severe thalassemic patients in two university hospitals in Bangkok: Experiences of caregivers
Surachai Kotirum*, Pattara Leelahavarong*, Kleebsabai Sanpakit, Suradej Hongeng,
Yot Teerawattananon*, Sripen Tantivess*
*Health Intervention & Technology Assessment Program, Ministry of Public Health, Faculty of Medicine Siriraj
Hospital, Mahidol University, Faculty of Medicine Ramathibodi Hospital, Mahidol University
This qualitative research used purposive sampling through in-depth interviews from main caregivers
whose severe ex-thalassemic children underwent successful hematopoietic stem cell transplantation
.-.
(HSCT). Participated caregivers were interviewed using a semi-structured questionnaire based on openended questioning and tape-recorded after receiving their informed consent. Transcripts of the interviewed
were created verbatim and examined using content analysis.
Results revealed that HSCT treatment procedure requires comprehensive understanding and cooperation from patients and their families. Economic household burden is the main hindrance for accessibility toward this service owing to its high direct non-medical costs as well as service charges although
HSCT can be reimbursed from all Thai health insurance schemes.
It is very crucial to prevent new thalassemic cases in order to alleviate the impact on the resource
allocation for treating a preventable disease in both household and public sectors. Therefore, public health
policy makers should consider creating a disease awareness campaign among citizens as well as healthcare
personnel who should have the comprehensive understanding about potential obstacles of the patients or
families and should commit to perform more effective thalassemia screening and prevention both in policy
and routine practice aspects.
Keywords:
hematopoietic stem cell transplantation, thalassemia, caregiver, experience, impact, qualitative

research, Thailand

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198

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200

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.

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-]
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- ]
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)
202
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- ]
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204
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.-.
. , , ,
, , , .
.
(IHPP)
(HITAP).

. .
: ; . -.
. Wu J, Mu PF, Tsay SL, Chiou TJ. Parental experience of family
stress during hematopoietic stem cell transplantation of pediatric
patients in germ-free isolation in Taiwan. Cancer Nurs 2005;28:36371.
. Forinder U. Bone marrow transplantation from a parental perspective. J Child Health Care 2004;8:134-48.
. Hsieh HF, Shannon SE. Three approaches to qualitative content
analysis. Qual Health Res 2005;15:1277-88.
. . :
(). : ; .
, ; -.
. Shanley C, Russell C, Middleton H, Simpson-Young V. Living
through end-stage dementia: the experiences and expressed needs
of family carers. Dementia 2004;10:325-40.
. Leelahavarong P, Chaikledkaew U, Hongeng S, Kasemsup V,
Lubell Y, Teerawattananon Y. A cost-utility and budget impact
analysis of allogeneic hematopoietic stem cell transplantation for
severe thalassemic patients in Thailand. BMC Health Serv Res
2010;10:209.
. Dhamcharee V, Romyanan O, Ninlagarn T. Genetic counseling for
thalassemia in Thailand: problems and solutions. Southeast Asian
J Trop Med Public Health 2001;32:413-8.
. , , ,
, , .
- . . :
(HITAP);
.
. Wasant P, Rajchagool C. Down syndrome parents support group
in Thailand Siriraj Hospital, fifteen years experience: a review. J
Med Assoc Thai 2009;92:1256-62.
. Chattopadhyay S. Rakter dosh-corrupting blood: the challenges of
preventing thalassemia in Bengal. India Soc Sci Med 2006;63:
2661-73.
. Tienthavorn V, Patrakulvanish S, Pattanapongthorn J, Voramongkol

N, Sanguansermsri T, Charoenkwan P. Prevalence of thalassemia
carrier and risk of spouse to have a severe thalassemic child in
Thailand [Presentation]. In: 11th National thalassemia conference
by Department of Health and Thalassemia Foundation of Thailand; 2005 Sep 1-2; Bangkok, Thailand.
. , . Family Focus
....
;:-.
. Lucarelli G, Gaziev J. Advances in the allogeneic transplantation
for thalassemia. Blood Rev 2008;22:53-63.
. Angelucci E, Baronciani D. Allogeneic stem cell transplantation
for thalassemia major. Haematologica 2008;93:1780-4.
. Gaziev J, Sodani P, Polchi P, Andreani M, Lucarelli G. Bone
marrow transplantation in adults with thalassemia: Treatment and
long-term follow-up. Ann N Y Acad Sci 2005;1054:196-205.
. Lawson SE, Roberts IA, Amrolia P, Dokal I, Szydlo R, Darbyshire
PJ. Bone marrow transplantation for beta-thalassaemia major: the
UK experience in two paediatric centres. Br J Haematol 2003;
120:289-95.
. Issaragrisil S. Hematopoietic stem cell transplantation in Thailand.
Bone Marrow Transplant 2008;42 Suppl 1:S137-S8.
206
.-.
*

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/

,
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Abstract
.-.
Responsiveness under different health insurance schemes and hospital types

Aungsumalee Pholpark*, Yongyuth Pongsupap, Wichai Aekplakorn, Samrit Srithamrongsawat*,
Rachanee Sunsern
*Health Insurance System Research Office, National Health Security Office, Faculty of Medicine Ramathibodi
Hospital, Mahidol University, School of Nursing, Mae Fah Luang University
The Statue on National Health System B.E 2552 section 7, the health system must promote human
value and dignity and attach importance to fairness and equity in society. This concept leads to an attempt
to capture interaction between providers and users in order to improve and develop the health service
system. Every person should be treated equally even though he/she accesses to care under different health
insurance schemes and hospital types. The purpose of this research was to assess the responsiveness of
Thai health care service system according to different types of national health insurance schemes and
health care facilities in 9 provinces. An exit survey of 6,507 out-patients covered by 3 health care schemes:
Civil Servants Medical Benefit Scheme (CSMBS), Social Security Scheme (SSS) and Universal Coverage
Scheme (UCS), was conducted. The health care settings included 4 hospital types: regional/general hospital, community hospital, university hospital and private hospital. The field survey period was from April
to June 2011.
The study revealed that there were significant difference between median scores, both overall and
hospital-type based, of responsiveness to users among three schemes in some domains and responsiveness scores under the CSMBS was higher than those from the SSS and UCS. Nevertheless, results from
logistic regression show that, when 75 percentile of score of each component was adopted as cut point for
high responsiveness, health insurance scheme was not significantly associated with all responsiveness
components, except choice: the scores of the CSMBS was significantly higher than those of the UCS. On
the other hand, type of hospital was significantly associated with responsiveness in all components. Overall, the score of private hospital was significantly higher than those of the others, whereas that of the
university hospital was significantly lower than the scores of the other hospitals, except choice, which was
significantly higher than in the university hospital than in the regional/general hospital.
Keywords: responsiveness, health service system, health insurance scheme, hospital
(Responsiveness)
()
WHO Bulletin ..()
(World Health Report)

..

..

()
208

()
(Reaction)
(Action)

()

(Standardization)
(Measurement of reaction: objective)()

()
. (Respect for person)
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()
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(Confidentiality)

O (Communication)

()

. (Client orientation)
O (Prompt attention)

( )

(Elective surgery)
O (Quality of basic amenities)

( )

O (Family
and community involvement)
(Access to social support networks)

O
.-.
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()

(,)

(,)

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-
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(Exit
survey)

()

-
-
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)

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(Kruskal-Wallis) .

/

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point)

(Specificity)

* (Family and
community involvement) (Access to social support networks)
** (Vignettes)

.-.
-
-
-

-
-
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//
././
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)

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.-.
214

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)
.-.
. (%CI ., .)

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/
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216

()
Lerberghe(,)

/

/

.-.
. De Silva A. A framework for measuring responsiveness. Geneva:

World Health Organization, unpublished document, 1999.
. World Health Organization. The health system responsiveness:
analytical guideline for multi-country survey study; 2005.
. De Silva A, Valentine N, Kawabata K, Darby C, Murray CJL.
Health systems Responsiveness: concepts and domains; 2002;
Available from website: http:\\www.who.int. Evidence and Information for Policy.
. , .
:
. ; ;:-.
. Pongsupap Y, Boonyapaisarncharoen T, Lerberghe WV. The perception of patients using primary care units in comparison with
conventional public hospital outpatient departments and prime
mover family practices: an exit survey: Journal of Health Science
2005:14;475-83.
. Pongsupap Y, Lerberghe WV. Choosing between public and private or between hospital and primary care: responsiveness, patientcentredness and prescribing patterns in outpatient consultations in
Bangkok. Tropical Medical and International Health 2006a:11:
81-89.
. Pongsupap Y, Lerberghe WV. Is motivation enough? Responsiveness, patient-centredness, medicalization and cost in family practice and conventional care settings in Thailand. Human Resource
for Health 2006b;4,19.
. Maister D. The psychology of waiting lines. In: Czepiel JA, Solomon
MR, Surprenant CF, editors. The service encounter: managing
employee/customer interaction in service businesses. Lexington,
MA, USA.: Lexington Books; 1985.
. ..
. Murray CJL, Kawabata K, Valentine N. Peoples experience versus peoples expectations. Health Affairs 2001;20:21-4.
. Murray CJL, Frenk J. A framework for assessing the performance
of health systems. Bulletin of the World Health Organization
2000;78:717-31.
. World Health Organization. The World health report 2000: health
system: improving performance; 2000.
218
.-.
*,

*,
*,
*,
(Collaborative Project
to Increase Rural Doctors: CPIRD)
CPIRD , ,
Survival analysis
CPIRD %
% Hazard ratio .
. CPIRD (p<.)
CPIRD CPIRD
% % Hazard ratio .
. CPIRD (p
= .) CPIRD
.
CPIRD
CPIRD
: (CPIRD), ,
Abstract
Rural retention of medical graduates trained by the collaborative project to increase rural doctors
(CPIRD)
Nonglak Pagaiya*,, Lalitthaya Kongkam, Warangkhana Worarat*,, Sanya Sriratana*,, Krisada
Wongwinyou*,
*Human Resources for Health Research and Development Office, International Health Policy Program, Thailand
(IHPP) Maharat Nakhon Ratchasima Hospital
The collaborative project to increase rural doctors (CPIRD) has been implemented since 1995. This
study therefore aims to assess whether the medical graduates trained by the CPIRD project were retained
.-.
in rural areas longer than those trained by regular training project.

The total of 1,093 CPIRD medical graduates and 6,064 medical graduates from regular training project
during 2001 - 2007 were included. The data was traced back from 2001 to 2010 in relation to their mobility.
Survival analysis was used for data analysis.
The study found that at the 4th year of their work, 69% of CPIRD medical graduates were retained in
the Ministry of Public Health (MoPH) compared to 59% of those trained by regular training project were.
Harzard ratio was 0.66 (p<0.001) and it indicated that normal track medical graduates had a probability to
resign from the MOPH 1.5 times than that of the CPIRD, significantly. After 3 years of public compulsory
work ended, 52% of CPIRD medical graduates were retained at rural hospitals while 47% of the normal
track medical graduates were. Harzard ratio was 0.88 (p= 0.001) and it indicated that normal track medical graduates had greater chance to move out of rural areas 1.14 times than that of the CPIRD ones, significantly. The median survival time in rural of the CPIRD medical graduates was declined from 10 years to 4
years, comparing to that of the normal track medical graduates that was declined from 6.5 years to 3 years.
Although physicians under the CPIRD project have higher rural retention, the median survival time
in rural had declined over 10 years and it become close to that of the normal track physicians. The trends
indicated that the improvement of the CPIRD project is needed in order to attract and retain more physicians in rural areas.
Keywords: the collaborative project to increase rural doctors (CPIRD), physicians, rural retention
, ()

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:
-

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analysis

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%

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%
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hazard ratio .
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10
15
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entry = 2000
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.

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224

CPIRD
%
%
CPIRD
() CPIRD

hazard ratio
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.
.
CPIRD (p = .)

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) ( )
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15
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CPIRD
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CPIRD
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.-.
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()
(Education intervention)
(Financial intervention)
(Regulation)
(Personal and Professional support interventions)

(-)
(-)
()
()

()
()

()

()

-

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CPIRD
hazard ratio
.
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CPIRD
Hazard ratios
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CPIRD

CPIRD

,

CPIRD
226
CPIRD
. Noree T, Chokchaichan H, Mongkolporn V. Abundant for the few,

shortage for the majority: The inequitable distribution of doctors
in Thailand. In Thailand Country Report; 2005.
. .
.. . : ;
.
. .
. :
; .
. . . :
; .
. . [
]. . . http://
cpird.in.th/main/nose/4
. .
. : ; .
. Dunbabin JS. McEwin K, Cameron I. Postgraduate medical placements in rural areas: their impact on the rural medical workforce.
Rural Remote Health 2006;6:481.
. Somers, Strasser and Jolly. What does it take? The influence of
rural upbringing and sense of rural on medical students intention
to work in rural environment. Rural and remote health.[Internet].
2007. [cited 22 July 2011]. Available from: http://rrh.deakin.edu.au
. Dunbabin JS, Levitt L. Rural origin and rural medical exposure:

Their impact on the rural and remote medical workforce in Australia. Rural and Remote Health. [Internet]. 2003. [cited 22 July
2011].Available from: http://rrh.deakin.edu.au
. Laven Gillian; Wilkinson David. Rural doctors and rural backgrounds: How strong is the evidence? A systematic review. Aust
J Rural Health 2003;11:277-84.
. Halaas GW, Zink T, Finstad D, Bolin K, Center B. Recruitment
and retention of rural physicians: outcomes from the rural physician associate program of Minnesota. J Rural Health 2008;24:34552.
. Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The
role of nature and nurture in recruitment and retention of primary
care physicians in rural areas: A review of literature. Acad Med
2002;77:790-8.
. Rabinowitz HK, Diamon JJ, Markham FW, Rabinowitz C. Longterm retention of graduates from a program to increase the supply
of rural family physicians. Acad Med 2005;80:728-32.
. Gardiner M, Sexton R, Kearns H, Marshell K. Impact support
initiatives on retaining rural general practitioners. Aust J Rural
Health 2006;14:196-201.
. Reid S. Monitoring effect of the new rural allowance for health
professionals [Research project report]. [Internet]. 2004. [cited 22
July 2011].Available from: http://healthlink.org.za/ uploads/ files/
rural_allowance.pdf
. Durey, Macnamara and Larson. Towards a health career for rural
students: Cultural and structural barriers influencing choices. Aust
J Rural Health 2003;11:145-50.
. .

. ;:.
. Rourke J. Increasing the number of rural physicians. [Internet].
2008. [cited 7 May 2008]. Available from: http://www.cmaj.ca/
cgi/reprint/178/3/322.pdf
. Humphreys JS, Jones MP, Jones JA, Mara PR. Workforce retention in rural and remote Australia: Determining the factors that
influence length of practice. [Internet]. 2002. [cited 7 July 2002].
Available from: www.mja.com.au/public/issues/ 176_10_200502/
hum10169_fm.pdf
.-.
*,
*,
*,
*,
*,

survival analysis

: , ,
Abstract
Impacts of financial measures on retention of doctors in rural and public health facilities
Nonglak Pagaiya*,, Sanya Sriratana*,, Krisada Wongwinyou*,, Chiraporn Lapkom*,, Warangkhana
Worarat*,
*Human Resources for Health Research and Development Office, International Health Policy Program
This study aimed to assess the impact of a financial measure on public and rural facility retention of
physicians in Thailand. It used a retrospective approach using secondary data from the Ministry of Public
Health (MoPH). The study population included all physicians who graduated and entered the workforce
during 2001-2007, and the data were retrieved from 2001-2011. Survival analysis was used.
Results showed that the high turnover rate of young physicians was still persistent. Large proportions of physicians, at about 30%, resigned before the 3-year compulsory contract ended, and this trend
repeated even after the financial measure was implemented. Resignations from MoPH have increased
since 2001, and the rate remained high after the increase of special allowance. Rural retention was low,
especially after 3 years of compulsory public services. The proportion of physicians retained in the rural
area after the 3-year compulsory period was about 20-24%, and this trend repeated even after implementation of the financial measures in 2009.
The results suggested that to retain physicians in the rural area we need both the financial and nonfinancial measures in an appropriate combination. Non-financial measures such as, working close to hometown, opportunities for specialist training, improvement of work environment and infrastructure would
be important for rural retention of physicians as well.
Keywords: Financial incentive, doctors, rural retention
228

, ()

,
()
()

,
(The Collaborative Project to Increase Rural Doctors- CPIRD)
(One District One DoctorODOD)
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( , )

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.
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.
.
(Survival Probability) ()
Mean survival (yr)
(mean survival years) -
232
survivor function

(survivor function) .
. .

survivor function .
. .

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Survivor function
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(Survival Probability) (-)
(mean survival years) -
.-.

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f

(.)
234
. .
. : ; .
. .
. :
; .
. WHO. Increasing access to health workers in remote and rural
areas through improved retention: Global policy recommendations.
WHO Geneva; 2010.
. , , ,
, .
: .
;:-.
. , , ,
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.
;:-.
. . . :
; .
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. Noree T, Chokchaichan H, Mongkolporn V. [Internet]. 2005. Abundant for the few, Shortage for the majority: The inequitable distribution of doctors in Thailand, Thailands Country paper. [cited
2011 March 5]. Available from: http://www.aaahrh.org/reviewal/
1166639104_Thailand-Revised.pdf
. . :
. : ;
.
.-.
:

*
(health system governance)

fitness
to practice
: , ,
Abstract
Good Governance Mechanisms for Medical Profession Regulations in the United Kingdom, New
Zealand and South Africa
Paisan Limstit*
*Health Law and Ethics Center, Faculty of Law, Thammasat University
Medical council is the core component of health system governance and the regulatory body of
medical profession in many countries. In the case study of the medical councils in the United Kingdom,
New Zealand and South Africa, they have development and changes from time to time so as to protect,
promote and maintain the health and safety of the public and to keep the public trust and confidence. The
study is a qualitative and documentary research and aims to study the philosophy, conceptual framework
and the role of these medical councils as an organization regulating the medical profession, and to propose the good governance to be applied to the Medical Council of Thailand as appropriate.
The results showed that Medical Councils of these countries have good governance mechanisms, especially, the General Medical Council (GMC) in the UK which is the model of the Medical Council of Thailand. The reform or changes of the these medical council have been developed with its aims of effective,
accountable with greater patient and public involvement and with faster, fairer and more transparent
procedures in making decisions on fitness to practice of alleged physicians.
Keywords: good governance, regulation of medical profession, medical council
236

(General Medical Council: GMC),
(Medical Council of New Zealand)
(Health
Professions Council of South Africa)
(regulatory body)
(British Medical Association)

()

()
.. ..

,

(lay
members),
(good medical practice)
, Council for Healthcare Regulatory Excellence (CHRE)

CHRE

Health and Disability Commissioner (HDC)
.-.

()
()
()
()

.
(patient safety)
(regulator)

/

fitness to practice

(good medical practice)

/
(documentary research and qualitative research)
238
(trust)

(medical association)

) (independence)

(regulatory body)

()
O
(independent of
health professionals themselves)

O

NHS (National Health
Service)

(lobby)

()

(the best interest of patients
and the public)
regulator

regulator

(dispassionate) (accountable) (just)

(registration fees/ annual fees)

.-.

(Privy Council)

Appointments Commission

/
) (conflict of
interests)

()

(professional organisations)
()
(good faith) (impartial)

) (transparency)

register of interests()

fitness to practice
()

240

(public inquiry)

) (accountability)
(General Medical Council: GMC)

()
-
-
-

.
-
GMC
-
, ,

-

Council for
Healthcare Regulatory Excellence (CHRE)

fitness to
practice
Fitness to Practice Panel
fitness to practice ()
CHRE
CHRE

Fitness to Practice Panel

CHRE
General Dental Council (GDC), General Optical Council (GOC), General

Pharmaceutical Council (GPhC), Nursing and Midwifery Council (NMC), Health Professions Council
(HPC)

fitness to practice
.-.

(health practitioner)

(
())

(practitioner), (intern)
(student)
()
(impairment)
,

()
)
(public participation)

(healthcare regulators)

(lay
members)

(Nursing and Midwifery Council)
Health Professions Council
()
/
(consultation)

) fitness to practice

242

fitness to practice

fitness to practice
Medical Practitioners Tribunal Service

(MPTS)
fitness to practice (adjudication reform())

Health Practitioners Disciplinary Tribunal
(HPDT)

(Health Professions Council of
South Africa - HPCSA) fitness to practice

HPCSA
(professional board)

Medical and Dental Board
(professional
conduct committee)

(an independent agency)
()
,

(health care providers) HDC

/
HDC

NHS Trust
Primary Care Trust (PCT), Patient Advice and Liaison
Services (PALS)
,
Independent Complaints Advocacy Services (ICAS)
NHS
Citizens Advice Bureau

(The Patients Rights Charter())

(professional board)
.-.
viders)

()

(no-fault compensation)

()
...
......

(General Medical Council),
(Medical Council of New Zealand)
(Health
Professions Council of South Africa)
(regulatory body)

(health care pro-
244

()

fitness to practice
(health system governance)

..
)
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...
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)
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)
... ..

)

( - )

)
Council for
Healthcare Regulatory Excellence (CHRE)

(.. )

)

Medical Prac-
246
titioners Tribunal Service (MPTS)

Health Practitioners Disciplinary Tribunal
fitness
to practice
)

:

(.)

. Beecham L. BMAs annual meeting expresses no confidence in

GMC. BMJ 2000;321:69.
. United Kingdom. Department of Health. Reform of the General
Medical Council: A paper for consultation. London; 2002.
. Medical Act of 1983. c. 54. (26 July 1983) (United Kingdom);
Health Practitioners Competence Assurance Act of 2003. No 48
(18 September 2003) (New Zealand); Health Professions Act 56 of
1974. (9 October 1974) (South Africa).
. United Kingdom. Secretary of State for Health by Command of
Her Majesty Trust, Assurance and Safety - The Regulation of
Health Professionals in the 21st Century. London; 2007. p. 24.
. New Zealand. Medical Council of New Zealand. Candidate Information on the Terms and Conditions of Appointment to the Medi-
cal Council of New Zealand. Wellington; 2005.

. Health Practitioners Competence Assurance Act of 2003. No 48
(18 September 2003); Schedule 3.
. General Medial Council [Internet]. Guidance on the Register of
Interests and Conflicts of Interest. [cited 2012 March 1]. Available
from: URL: http://www.gmc-uk.org/about/register.asp
. Fitness to Practise Panels. Available from: URL: http://www.gmcuk.org/concerns/hearings_and_decisions/fitness_to_practise_panels.asp
. General Medial Council [Internet]. Members code of conduct
[cited 2012 March 5]. Available from: URL: http://www.gmcuk.org/about/register_code_of_conduct.asp
. Council for Healthcare Regulatory Excellence [Internet] [cited 2012
March 7]. Available from: URL: https://www.chre.org.uk/about/
279/
. Health Practitioners Competence Assurance Act of 2003. No 48
(18 September 2003); section 34.
. ETHICAL RULES OF CONDUCT FOR PRACTITIONERS REGISTERED UNDER THE HEALTH PROFESSIONS ACT, 1974 (4
August 2006) under Health Professions Act 56 of 1974. (9 October 1974)
. United Kingdom. Secretary of State for Health by Command of
Her Majesty Trust, Assurance and Safety - The Regulation of
Health Professionals in the 21st Century. London; 2007: 24-5.
. General Medial Council [Internet]. Adjudication reform [cited 2012
March 10]. Available from: URL: http://www.gmc-uk.org/concerns/
hearings_and_decisions/mpts.asp
. Health and Disability Commissioner Act of 1994. No 88 (20
October 1994) (New Zealand)
. South Africa. Health Professions Council of South Africa. GUIDELINES FOR GOOD PRACTICE IN THE HEALTH CARE PROFESSIONS: NATIONAL PATIENTS RIGHTS CHARTER.
PRETORIA; 2008.
. . ...
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.
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. (.-.) . (.-.)
. (.-.)
. (.-.)
. (.-.) .
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248
Abstract
Relationship and relative risk of cardiovascular diseases attributable from smoking: A systematic
review and meta-analysis
Jiraboon Tosanguan*, Suchunya Aungkulanon*,, Hathaichanok Sumalee*,
Kanitta Bundhamcharoen*,
*International Health Policy Program Thailand, Burden of Diseases Project, Thailand **
Cigarette smoking is one of the most important causes of chronic diseases and immature deaths
globally which has led to numerous epidemiological studies conducted to identify the association between smoking and various types of diseases. The objectives of this study are systematically review existing epidemiological literature on cardiovascular risk from smoking and to synthesize a pooled relative
risks based on meta-analysis of those literature. Review protocol has been developed to identify relevant
and comprehensive keywords and to ensure appropriate inclusion/exclusion criteria are applied without
bias.
Between 1994- 2011, 881 and 272 papers have been identified from the literature search for ischaemic
heart diseases (IHD) and cerebrovascular diseases (CVD) respectively. This was later reduced to 14 for
IHD and 20 for CVD. When metaanalysis was performed, it was found that the relative risk of developing IHD from smoking was 2.14 (1.76-2.60) for men and 2.84 (1.90-4.24) for women, while for CVD, it was
1.66 (1.43-1.93) for men and 2.18 (1.67-2.85) for women. For sub-group analysis, it was found that for Asian
population, the relative risk of developing IHD was 2.15 (1.69-2.75) for men and 1.99 (1.18-3.34) for women,
and for CVD, it was 1.31 (1.19-1.44) for men and 1.60 (1.25-2.04) for women.
This study has confirmed the harm from smoking and the association between smoking and cardiovascular morbidity. The fact that relative risk in Asian population is relatively lower compared to the rest
of the World does not imply that there is less harm from cigarette smoking in this population but may
occur as a result of significant presence of other risk factors, such as quality and access to medical treatment for hypertension and dyslipidaemia, within the population.
Keywords:
smoking, coronary heart disease, cerebrovascular disease, relative risk, systematic review, metaanalysis

()
() .
.
.

()
- -
(relative
risk)
Cancer Prevention Study
I II (CPS I&II) Asia-Pacific Cohort Study
Collaboration Liu ()

(-)
.. ()
.-.
(Systematic Review)
(Meta-Analysis)

(subgroup analysis)

cohort case-control
(keyword)
. :
O (ischaemic heart
disease OR coronary heart disease OR angina
pectoris OR myocardial infarction OR chronic heart
failure)
O (stroke OR cerebrovascular disease OR ischaemic stroke OR haemorrhagic stroke OR subarachnoid haemorrhage OR
intracerebral haemorrhage OR intracranial haemorrhage OR cerebral infarction)
. : (smoking
OR tobacco OR cigarette)
. :
(cohort OR case control)
. : (odds
ratio OR relative risk OR hazard ratio)

(search engine) AND

Pubmed (http://www.ncbi.nlm.nih.gov/pubmed)

Systematic Review

(Systematic) (Explicit)

(MetaAnalysis)
(Bias)

(generalisability)

(heterogeneity)
250

(inclusion criteria) (exclusion criteria)
(Inclusion Criteria)

(abstract)

( )
-
Pubmed
(Exclusion Criteria)

(full text)
. odds ratio, relative

risk, hazard ratio
(sex-specific)
. cohort
.

Randomized Controlled Trial Chalmers Scale
Jadads Scale
(objective)
observational study

drop-out
rate

RevMan 5
heterogeneity

fixed effect random effect fixed effect
sampling error
random effect
sampling error
Degree of Heterogeneity I2 25%
p value 0.10
random effect
.

( )

( ) () ()
() ()
() () () ()
() cohort case-control
( . .)

. .
(subgroup analysis)
.
. . I2
(> 75%) p value 0.10
heterogeneity
.-.
Papers idened through searches of Pubmed using keywords: (smoking OR

tobacco OR cigaree) AND (ischaemic heart disease OR coronary heart
disease OR angina pectoris OR myocardial infarcon OR chronic heart
failure) AND (cohort OR case control) AND (relave risk OR Odds rao
OR Hazard Rao) (n=881)
3 paper could not be

obtained
Excluded on basis of tle and abstract if irrelevant, not

about risk of IHD from smoking etc. (n=858)
Evaluated in Details (n=20)

Excluded if
RR not sex-specic (n=)
Studies on risk of IHD comparing

smokers and non-smokers with sexspecic RR (n=14)
Meta-analysis performed using Review Manager 5
(Systematic Review) (IHD)

(IHD)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Liu et al 1998 [4]

Lawlor et al 2008 [10]
Jee et al 2007 [11]
Kawano et al 2006 [12]
Rastogi et al 2005 [13]
Sitas et al 2004 [14]
Mahonen et al 2004 [15]
Engstrom et al 2000 [16]
Liaw et al 1998 [17]
Prescott et al 1998 [18]
Tavani et al 2004 [19]
Bosetti et al 1999 [20]
Reuterwall et al 1999 [21]
Pais et al 1996 [22]
1 million
648,346 men
234,399 women
1,925 cases
309 cases
16,230 cases
>130,000
9,315 women
17,538
>25,000
314 cases
1,230 cases
2,246 cases
200 cases
Cohort
Cohort
Cohort
Case-control
Case-control
Case-control
Pooled
Cohort
Cohort
Pooled
Case-control
Case-control
Case-control
Case-control

( ) ()
() () () ()
()
cohort case-control
.

( )

252
(Meta-Analysis) (IHD) (ROW Rest of

the World )
(Meta-Analysis) (LC) (ROW Rest of

the World )
.-.
( )
.
.
(subgroup analysis)

. .
heterogeneity subgroup
(I2= 92%)

I2 69% 62%
I2 0%
. .
. .

(IHD)
(Meta-Analysis)

RR [% CI]
()
()
()
()
. [.-.]
. [.-.]
. [.-.]
. [.-.]
Papers idened through searches of Pubmed using keywords: (smoking OR

tobacco OR cigaree) AND (stroke OR cerebrovascular disease OR ischaemic
stroke OR haemorrhagic stroke OR subarachnoid haemorrhage OR
intracerebral haemorrhage OR intracranial haemorrhage OR cerebral
infarcon) AND (cohort OR case control) AND (relave risk OR Odds rao
OR Hazard Rao) (n=727)
Excluded on basis of tle and abstract if irrelevant, not
about risk of stroke from smoking etc. (n=694)
Evaluated in Details (n=33)
Studies on risk of stroke comparing

smokers and non-smokers with sexspecic RR (n=20)
Excluded if
1. No specic RR on stroke (n=2)
2. RR on stroke but not comparing smokers
and non-smoker (n=1)
3. RR not sex-specic (n=9)
4. Full paper could not be obtained (n=1)
Meta-analysis performed using Review Manager 5
(Systematic Review) (stroke)
254
(stroke)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Ueshima et al 2004 [23]

Honjo et al 2010 [24]
Mannami et al 2004 [25]
Colditz et al 1988 [26]
Kelly et al 2008 [27]
Kenfield et al 2008 [28]
Lam et al 2007 [29]
Liu et al 1998 [4]
Lam et al 2002 [30]
Kenfield et al 2010 [31]
Iso et al 2004 [32]
Kurth et al 2003 [33]
Kurth et al 2010 [34]
Robbins et al 1994 [35]
Wannamethee et al 1995 [36]
Lu et al 2008 [37]
Kawachi et al 1993 [38]
Bhat et al 2008 [39]
Juvela et a 1993 [40]
Yamada et al 2003 [41]
9,638
296,000
41,200
118,539 women
169,871
102,635 women
56,167
1 million
1,268
104,519 women
94,683
22,022 men
39,783 women
22,071 men
7,735 men
45,449 women
117,006 women
466 cases
278 cases
109,293
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Cohort
Case-Control
Case-Control
Cohort
(Meta-Analysis) (stroke) (ROW Rest

of the World )
.-.
(Meta-Analysis) (stroke) (ROW Rest

of the World )

background risk
background risk

()
() ()

background risk

(stroke) (MetaAnalysis)
RR [ % CI]
()
()
()
()
. [.-.]
. [.-.]
. [.-.]
. [.-.]
Stellman ()

Liu ()
256

.
.

(,,)

case-control study
relative risk odds ratio

(rare diseases)

(orphan drugs)

odds ratio case-control

relative risk cohort

Bias
observational study
random sampling
selection bias case-control Rastogi
Pais

Cohort
attrition bias drop-out

publication
bias
Pubmed
.-.
(Burden of Disease).
.
. Lawlor DA, Song YM, Sung J, Ebrahim S, Smith GD. The
association of smoking and cardiovascular disease in a population
with low cholesterol levels: A study of 648 346 men from the
Korean National Health System Prospective Cohort Study. Stroke
2008;39:760-7.
. Jee SH, Park J, Jo I, Lee J, Yun S, Yun J-E, et al. Smoking and
atherosclerotic cardiovascular disease in women with lower levels
of serum cholesterol. Atherosclerosis 2007;190:306-12.
. Kawano H, Soejima H, Kojima S, Kitagawa A, Ogawa H. Sex
differences of risk factors for acute myocardial infarction in Japanese patients. Circ J 2006;70:513-7.
. Rastogi T. Bidi and cigarette smoking and risk of acute myocardial infarction among males in urban India. Tobacco Control 2005;
14:356-8.
. Sitas F. Tobacco attributable deaths in South Africa. Tobacco
Control 2004;13:396-9.
. Mahonen MS. Current smoking and the risk of non-fatal myocardial infarction in the WHO MONICA Project populations. Tobacco Control 2004;13:244-50.
. Engstrm GT, Berglund P, Hansen G, Hedblad OB, Janzon L.
Incidence of myocardial infarction in women. A cohort study of
risk factors and modifiers of effect. J Epidemiol Community Health
2000;54:104-7.
. Liaw KM, Chen CJ. Mortality attributable to cigarette smoking in
Taiwan: a 12-year follow-up study. Tobacco Control 1998;7:1418.
. Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking
and risk of myocardial infarction in women and men: longitudinal
population study. BMJ 1998;316:1043-1047.
. Tavani A, Bertuzzi M, Gallus S, Negri E, Lavecchia C. Risk
factors for non-fatal acute myocardial infarction in Italian women.
Preventive Medicine 2004;39:128-34.
. Bosetti C, Negri E, Tavani A, Santoro L, Vecchi CL. Smoking
and acute myocardial infarction among women and men: a casecontrol study in Italy. Preventive Medicine 1999;29:343-8.
. Reuterwall C, Hallqvist J, Ahlbom A, De Faire U, Diderichsen F,
Hoqstedt C, et al. Higher relative, but lower absolute risks of
myocardial infarction in women than in men: analysis of some
major risk factors in the SHEEP study. J Intern Med 1999;246:16174.
. Pais P, Pogue J, Gerstein H, Zachariah E, Savitha D, Jayprakash
S, et al. Risk factors for acute myocardial infarction in Indians: a
case-control study. Lancet 1996;348:358-63.
. Ueshima H, Reza Choudhury S, Okayama A, Hayakawa T, Kita
. World Health Organisation: MPOWER: A policy package to reverse the tobacco epidemic. In. Switzerland; 2008.
. , , ,
, .
4 ..2551-2552.
.
. .
..2552.
(.). 2552.
. Liu BQ, Peto R, Chen ZM, Boreham J, Wu YP, Li J-Y et al.
Emerging tobacco hazards in China: 1. Retrospective proportional
mortality study of one million deaths. BMJ 1998;317:1411-22.
. Stellman SD, Takesaki T, Wang L, Chen Y, Citron ML, Djordjevic
MV, et al. Smoking and lung cancer risk in American and Japanese men: An international case-control study. Cancer Epidemiology Biomarkers & Prevention 2001;10:1193-9.
. Djordjevic MV, Eixarch L, Bush LP, Hoffmann D. A comparison
of the yields of selected components in the mainstream smoke of
the leading US and Japanese cigarettes. In: CORESTA Congress
Proceedings: 1996; Yokohama, Japan; 1996. p. 200-7.
. Haiman CA, Stram DO, Wilkens LR, Pike MC, Kolonel LN,
Henderson BE, et al. Ethnic and racial differences in the smokingrelated risk of lung cancer. N Engl J Med 2006;354:333-42.
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Jiang C, et al. Impact of smoking and smoking cessation on lung
cancer mortality in the Asia-Pacific region. Am J Epidemiol
2007;165:1280-6.
. .. 2547.
258
Y, Kadowaki T, et al. Cigarette smoking as a risk factor for stroke

death in Japan: NIPPON DATA80. Stroke 2004;35:1836-41.
. Honjo K, Iso H, Tsugane S, Tamakoshi A, Satoh H, Tajima K, et
al. The effects of smoking and smoking cessation on mortality
from cardiovascular disease among Japanese: pooled analysis of
three large-scale cohort studies in Japan. Tobacco Control
2009;19:50-7.
. Mannami T, Iso H, Baba S, Sasaki S, Okada K, Konishi M, et al.
Cigarette smoking and risk of stroke and its subtypes among
middle-aged Japanese men and women. The JPHC Study Cohort I.
Stroke 2004;35:1248-53.
. Colditz GA, Bonita R, Stampfer MJ, Willett WC, Rosner B,
Speizer FE, et al. Cigarette smoking and risk of stroke in middleaged women. N Engl J Med 1988;318:937-941.
. Kelly TN, Gu D, Chen J, Huang JF, Chen JC, Duan X, et al.
Cigarette smoking and risk of stroke in the chinese adult population. Stroke 2008;39:1688-93.
. Kenfield SA, Stampfer MJ, Rosner BA, Colditz GA. Smoking and
smoking cessation in relation to mortality in women. JAMA 2008;
299:2037-47.
. Lam TH, Li ZB, Ho SY, Chan WM, Ho KS, Tham MK, et al.
Smoking, quitting and mortality in an elderly cohort of 56 000
Hong Kong Chinese. Tobacco Control 2007;16:182-9.
. Lam TH, He Y, Shi QL, Huang JY, Zhang F, Wan ZH, et al.
Smoking, quitting, and mortality in a Chinese cohort of retired
men. Ann Epidemiol 2002;12(5):316-320.
. Kenfield SA, Wei EK, Rosner BA, Glynn RJ, Stampfer MJ,
Colditz GA. Burden of smoking on cause-specific mortality: application to the nurses health study. Tobacco Control 2010;19:24854.
. Iso H. Smoking cessation and mortality from cardiovascular
disease among Japanese men and women: the JACC study. Am J
Epidemiol 2005;161:170-9.
. Kurth T. Smoking and the risk of hemorrhagic stroke in men.
Stroke 2003;34:1151-5.
. Kurth T. Smoking and risk of hemorrhagic stroke in women.
Stroke 2003;34:2792-5.
. Robbins AS, Manson JE, Lee I, Satterfield S, Hennekens CH.
Cigarette smoking and stroke in a cohort of U.S. male physicians.
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. Wannamethee G, Shaper AG, Macfarlane PW. Heart rate, physical
activity, and mortality from cancer and other noncardiovascular
diseases. Am J Epidemiol 1993;137:735-48.
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women under 60 years of age related to alcohol intake and smoking habit. Cerebrovascular Diseases 2008;25:517-725.
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Rosner B, et al. Smoking cessation in relation to total mortality
rates in women. A prospective cohort study. Ann Intern Med
1993;119:992-1000.
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Giles WH, et al. Dose-response relationship between cigarette
smoking and risk of ischemic stroke in young women. Stroke
2008;39:2439-43.
. Juvela S, Hillbom M, Numminen H, Koskinen P. Cigarette
smoking and alcohol consumption as risk factors for aneurysmal
subarachnoid hemorrhage. Stroke 1993;24:639-46.
. Yamada S. Risk factors for fatal subarachnoid hemorrhage: the
Japan collaborative cohort study. Stroke 2003;34:2781-7.
. Libby PBR, Mann DL, Zipes DP. Braunwalds heart disease: a
Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: Saunders;
2007.
. Arakawa MMY, Taira K. Hypertension and stroke in centenarians,
Okinawa, Japan. Cerebrovasc Dis 2005;20:233-8.
.-.

.
.
.
)
)
Clinical practice guideline
: , , ,
260
Abstract
Physicians attitudes, obstacles, and sources about the use of cost-effectiveness information in
clinical practice in Thailand: a cross-sectional survey
Win Techakehakij*, Rungrote Subsoontorn, Nutthawut Chuaihom, Mallika Bunneum, Nalat

Yingtaweewattana, Primrata Chumsri
*Suratthani Hospital, Medical Student at Suratthani Hospital
Efficiency in clinical practice has become of increasing concern in the healthcare system in Thailand.
Cost-effectiveness analysis is a concept that helps in the efficient allocation of healthcare resources; however, evidence showing the use of the cost-effectiveness (CE) information in clinical practice in Thailand is
limited. The aim of this study is to assess physicians attitudes towards the use of CE information in
clinical practice.
A cross-sectional survey was carried out to collect information from 140 physicians at Suratthani
Hospital, a central hospital in Southern Thailand, during 12-26 March 2012. The questionnaire consisted
of 3 main parts: physicians attitudes, obstacles in the use of CE in clinical practice, and sources of CE
information.
The results showed that the sample response rate was 52.1%. Concerning physicians attitudes, 68.5%
of physicians agreed that it is appropriate to consider CE information in the clinical decision-making
process. 76.7% of physicians agreed that cost containment in current healthcare system is necessary. The
main obstacles in the use of CE in clinical decisions are: 1) unwillingness to accept that healthcare resources are limited by the public; and 2) social expectation for medical services exceeding the capacity of
public health system. Results pertaining to the source of CE information showed that 96% of physicians
attributed CE results to clinical practice guidelines. In addition, CE information from the same source
gains more attention from physicians when presented verbally rather than in written form.
Increasing the use of CE information in clinical decision-making is one way to improve efficiency in
resource allocation in the healthcare system. Findings from this study can be used to inform policies that
promote more efficient utilization of healthcare resources.
Keywords: health economics, attitude, physician, clinical decision

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266
. .
.. . [].
[ ]. : http://
61.19.241.70/rkjnew/front/ShowList.aspx?LawGroupID=187583
&rkjTypeID=1
. World Health Organization. Total health expenditure of Thailand.
[Internet]. [cited 2012 Mar 20]. Available from: http://www.who.int/
countries/tha/en/
. World Health Organization. The National Drug Policy. [Internet].
[cited 2012 Mar 20]. Available from: http://www.searo.who.int/en/
Section313/Section1525_10864.htm
. Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-effectiveness analysis. Cost-effectiveness in health and medicine. New
York: Oxford University Press; 1996.
. Oya Eddama and Joanna Coast. A systematic review of the use of
economic evaluation in localdecision-making. 2008;86:129-41.
. Wu O, Knill-Jones R, Wilson P, Craig N. The impact of economic
information on medical decision making in primary care. 2004;
10:407-11.
. Ginsburg ME, Kravitz RL, Sandberg WA. A survey of physician
attitudes and practices concerning cost-effectiveness in patient care.
2000;173:390-4.
.-.
*
*
*
(Triage) Resuscitation Emergency Urgency

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(trauma)
(non trauma) (Triage) Resuscitation
Emergency Urgency

.

:
Abstract
Why dont Chiangmai people in need call emergency medical service?

Natcha Hansudewechakul*, Boriboon Chenthanakij*, Borwon Wittayachamnankul*
*Division of Emergency Medicine, department of Family Medicine, Chiang Mai University
Background: Acute illness and accidents are the leading cause of death in Thailand. Developing a
good systematic pre-hospital care can help reducing morbidity and mortality. To achieve this goal, the
Ministry of Public health has issued a policy for all hospitals in Thailand to set up an Emergency Medical
268
Service (EMS) system. Nevertheless, this service system is not widely acknowledged in Chiang Mai. Most
of the patients did not use the service and go to the hospital by themselves Objective: To determine reasons of underuse of Emergency Medical Service in patients visiting the Emergency room, Maharaj Nakorn
Chiang Mai hospital. Methods: This was a prospective observational study by means of questionnaires
filled by the patients or anyone accompanied them to the emergency room, Maharaj Nakorn Chiang Mai
hospital. Only 3 level of triage was used; level 1-Resuscitation, level 2-Emergency, and level 3-Urgency.
This study was conducted during the period from March to October 2011. Analysis was made by dividing
participants into 2 groups; patients coming to the emergency room by themselves, and the ones coming
by using EMS system. Results: There were 102 participants; 64 coming by themselves and 38 using EMS.
There were 44 traumatic patients, and 58 non traumatic patients. 4 participants were of triage level 1
Resuscitation, 42 of triage level 2 Emergency and 56 of triage level 3 Urgency. Sex, degree of education and
occupation were not related to EMS activation. Many reasons accounted for this problem; 64.1% of the
patients had their own vehicles, 50% did not know of the service, and 25% thought that their symptoms
were insufficient to activate EMS system. People in Chiang Mai learned of the EMS system through many
advertising media, in sequentially billboards, television, and radio programs. Conclusion: The reasons of
underuse of EMS system in Chiang Mai were: unknown of existence, failure to recognize the importance,
and doubt in the Emergency Medical Service systems.
Key words: Emergency Medical Service
()
(Pre-hospital care)
(-)
(Emergency
Medical Service system)
(Chain of survival)
(Stroke)
(Acute Myocardial infarction)
(,)

()
.

. .
..

.. ..
,

..

()

.-.

EMS
.. (
) (Trauma/Non
Trauma = /)
Urgency

(,)

(Triage) Resuscitation Emergency Urgency

(Inclusion criteria)
(Exclusion criteria) ..
..
n = [ Z2/2 P(1-P)]/e2 ...()

n =
=
= .
Z = (confidence coefficient) (1-)
P = =
P .
.
-
(http://www.chiangmaihealth.com/ems/
show_file_detail.php?ID=136)
e = = 0.1
n = [(1.96)2 * 0.83 * 0.17] / (0.1)2 =
)

) (triage)
Resuscitation Emergency
(Prospective observational study)
270
Urgency Suandok Triage

)
, head
injury GCS < ) (refer)
)
(triage)
Less-urgency Non urgency
Suandok Triage )

(Statistic analysis)

SPSS version .

..

.

- .
( .)
( .)
(trauma)
( .) (non trauma) ( .)
Resuscitation
( .) Emergency ( .)
Urgency ( .)
.
//
.
.

,

( .) ( .)
( .)
( .)

.

- . (SD
.) (
.) (
.) (trauma)
( .) (non trauma)
( .) Resuscitation Emergency (
.) Urgency ( .)
. /
.
.
.-.
(N=)

() (mean, SD)
(n=)
(n=)
p-value
.(.)
.
.
.(.)
.
.
Trauma
Non trauma
.
.
.
.
(Triage)
Resuscitation
Emergency
Urgency
.
.
.
.
.
.
.
.
.
.*
.
.
.
.
.*
/
/
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
* Pearson Chi-Square, ** Likelihood Ratio, Independent sample T-test
272
.*
.
.*
.**
.**
.**
.*

(N=)
.
.
.
.
.
.
.
.
.
.
.
.
()
.
.
.
.
.
.
.
.
(Triage)
(Triage) ()
Resuscitation Emergency Urgency
.
.
.
.
.
.
.
.
.
.
.
.
()
.-.
.
.
.
.
.
.
.
.
.
.
.
.
(Trauma)

( .) /
.

. /
( .)
()
(Non Trauma)
()
(n=)
Internet

*
.
.
.
.
.
(n= )
.
.
.
.
274
(Triage)
Resuscitation Emergency .
Resuscitation


/

Emergency

( )

.-.

/
( .) (
.)

First responder

/

First responder
Advance


276

(Seasonal variation)

Statistic/2.3.4-52.pdf
. Marson AC, Thomson JC. The influence of prehospital trauma
care on motor vehicle crash mortality. J Trauma 2001;50:917-20;
discussion 20-1.
. Husum H, Gilbert M, Wisborg T, Van Heng Y, Murad M. Rural
prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. J Trauma 2003;54:1188-96.
. Goldstein P, Lapostolle F, Steg G, Danchin N, Assez N, Montalescot
G, et al. Lowering mortality in ST-elevation myocardial infarction
and non-ST-elevation myocardial infarction: key prehospital and
emergency room treatment strategies. Eur J Emerg Med 2009;
16:244-55.
. Gladstone DJ, Rodan LH, Sahlas DJ, Lee L, Murray BJ, Ween JE,
et al. A citywide prehospital protocol increases access to stroke
thrombolysis in Toronto. Stroke 2009;40:3841-4.
. Acker JE 3rd, Pancioli AM, Crocco TJ, Eckstein MK, Jauch EC,
Larrabee H, et al. Implementation strategies for emergency medical services within stroke systems of care: a policy statement from
the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke
Council. Stroke 2007;38:3097-115.
. Le May MR, Davies RF, Dionne R, Maloney J, Trickett J, So D,
et al. Comparison of early mortality of paramedic-diagnosed STsegment elevation myocardial infarction with immediate transport
to a designated primary percutaneous coronary intervention center
to that of similar patients transported to the nearest hospital. Am
J Cardiol 2006;98:1329-33.
. -.
; 2000.
. Chenthanakij B. Quality of pre-hospital cares performed by Maharaj
Nakorn Chiang mai hospital. Chiang Mai Med J 2010;49:53-8.
. Kawakami C, Ohshige K, Kubota K, Tochikubo O. Influence of
socioeconomic factors on medically unnecessary ambulance calls.
BMC Health Serv Res 2007;7:120.
. Hjalte L, Suserud BO, Herlitz J, Karlberg I. Why are people
without medical needs transported by ambulance? A study of
indications for pre-hospital care. Eur J Emerg Med 2007;14:151-6.
. . . 1st ed.
: ; 2552.
. 100,000
.. 2548- 2552 Available from: http://bps.ops.moph.go.th/
.-.

PubMed MEDLINE

: , ,
Abstract
Scoping Review and Research Synthesis on the Financial Management of Oral Health Promotion
System for the Disabled in Thailand
Jutharat Chimruang*, Nithimar Sermsuti-Anuwat
*Faculty of Dentistry, Naresuan University, Institute of Health Promotion for People with Disability
Empirical evidence of oral health care and dental service delivery systems for people with disabilities in Thailand is needed. An important question for the national health policy-makers is how to improve
oral health promotion for disabled patients in healthcare priority-setting. The objective of this paper was
synthesis of common wisdom regarding financial management of the oral health promotion system for
the disabled people in Thailand. This study systematically reviewed the literature in PubMed and MEDLINE
databases and the unpublished-literature that reported data in Thailand, Japan, the United States of America,
Canada, and the Commonwealth of Australia. The relevance of 82 retrieved articles was reviewed for each
country based on its current oral-health insurance systems, cost-benefits, and healthcare financial management. Thirty-seven stakeholders commented on these findings and made suggestions by group panel.
This evidence supports the need to develop oral-healthcare policies to support dental care service, especially oral health promotion and prevention, and improvement of equity and quality of the disabled access to dental primary, secondary, and tertiary healthcare delivery systems in Thailand.
Key words: Disabled Persons, Oral Health, Health Care Economics and Organizations
278

)
)
)
/
/

)

()
MEDLINE Pubmed .. (Medical Subject Headings: MeSH) (Disabled
Persons[Mesh] OR Disabled Children[Mesh] OR
Mentally Disabled Persons[Mesh] OR Mental
Disorders[Mesh] OR Frail Elderly[Mesh]) AND (Oral
Health[Mesh] OR Stomatognathic Diseases[Mesh]
OR Stomatognathic System[Mesh] OR dental care
for disabled[Mesh] OR special needs dentistry) AND
(Health Care Economics and Organizations[Mesh])

..

(Grey literature)
.-.

.

.

..
.
..

() -
,
,

()
.

..
..
..
..

///

280
.

.

,

.

..

)

(-) )
(core package)
(-) )
(core package)
() (-)

.
.

.
.
.-.
Medicaid
FFS,
PPO,
HMO
ESHI
NHI(UC)
FFS,
EHI
FFS
Medicare
(UC)
Global budget
Medicare
(UC)
FFS
FFS
FFS,
,
FFS
16
FFS
FFS
: Universal Coverage (UC); Fee-For-Service (FFS); Employer Sponsored Health Insurance (ESHI); Preferred Provider Organization (PPO);
Health Maintenance Organization (HMO); National Health Insurance(NHI); Employee Health Insurance (EHI)
282

(Outpatient care budget: OP)
(Capitation)

(Promotion & Prevention service budget: PP)

(Personal care)
(School based)
()
)

(Outcomes)
(Performance based) )

(Fee For Service: FFS)

()

()

(Capitation)

(Fee schedule)
(Capped-fee
.-.
..
(UC)
/
*
*
*
- (
,
)
- (
, )
- (
)
- (
)
- (

)
- - (
-
-
)
- (

)
- ( )
- ()
FFS
FFS
FFS
FFS
FFS
-
FFS
FFS
FFS
: * ; Universal Coverage (UC) ; Fee-For-Service (FFS)
schedule) (Out-ofPocket)

(-)

284
..-
FFS,
FFS,
FFS, ,
FFS, PPO
FFS
..-; *
(direct out-of pocket); Fee-For-Service (FFS); Preferred Provider Organization (PPO)
.-.
. (Core package)
/
/

286

.

CUP CUP

(Fee schedule)
(Co-payment)

(Fixed-fee
schedule)
(Capped-fee schedule)
(Fee-For-Service)
.-.
.
(Standard fee schedule)
(Fee-for-service)
(Co-payment)
(Fixed fee schedule)
(Capped fee schedule)
.

(Social stigma)
288
(2555)

(.)
. Centre for Reviews and Dissemination. Systematic Review: CRDs

guidance for undertaking reviews in health care. York: University
of York; 2009.
. . :
. . :
; . -.
. Waldman HB, Swerdloff M. Health Insurance for children: A new
federal initiative and opportunity. J Dent Child 1998;65:136-9.
. Stephen T, Jonathan M, Alice M. Parental perceptions of unmet
dental need and cost barriers to care for developmentally disable
children. Pediatr Dent 2001;23:321-5.
. Shinsho F. New strategy for better geriatric oral health in Japan:
80/20 movement and Healthy Japan 21. Int Dent J 2001;51:200-6.
. Nakahara T. The health system of Japan. In: Raffel MW, editor.
Health care and reform in industrialized countries. University Park:
Pennsylvania State University Press; 1997. p. 105-133.
. Okamoto A. Public health of Japan 2001. Commemorative issue
for the 129th Annual Meeting of American Public Health Association, Atlanta, Georgia. October 21-25, 2001.
. . . .
: ; .
-.
. Leatt P, Williams AP. Canada. In: Raffel MW, editor. Health care
and reform in industrialized countries. University Park: Pennsylvania State University Press; 1997. p. 1-28.
. Lennox N, Bain C, Rey-Conde T, Purdie D, Bush R, Pandeya N.

Effects of a comprehensive health assessment program for Australian adults with intellectual disability: a cluster randomized trial.
Intern J Epidemiol 2007;36:139-46.
. Dixon A, Mossialos E, editors. Health care systems in eight countries: trends and challenges. London: The European Observatory
on Health Care Systems; 2002. p. 3-16.
. Deeble J. Medical services though Medicare. Canberra: National
Health Strategy Background Paper No. 2, Australia; 1991.
. , , .
.
. :
; .
. U.S. Department of Health and Human Services. Oral health in
America: a report of surgeon general. Washington DC, U.S.: Department of Health and Human Services; 2000.
. , , .

. 1. :
. -.
. , .

. . : ;
. -.
. Kawamura M, Sasaki T, Imai-Tanaka T, Yamasaki Y, Iwamoto Y.
Service-mix in general dental practice in Japan: A survey in a
suburban area. Aust Dent J 1998;43:410-6.
. Sukimoto K, Matsuo G. Comprehensive community dental practice-by the Miyagi Prefecture Dental Association. Dent Japan 1993;
30:157-63.
. Imai Y. Health care reform in Japan. Economics Department Working
Papers No.321. Organization for Economic Co-operation and Development; 2002.
. Spencer AJ. Narrowing the inequality gap in oral health and
dental care in Australia. Final report. Victoria: Australian Health
Policy Institute; 2004.
. Willcox S. A healthy risk? Use of private insurance. Final reports.
Canberra: National Health Strategy Background Paper No.4; 1991.
.-.
. .
*
(.)

.

(..)
. -
- ./. HbA1c<%
..
.
...
... HbA1c <% .
.

Abstract
Development of Diabetic Care System in Pua Contracting Unit for Primary Care, Nan Province
Kobkul Yodnarong*
*Pua Crown Prince Hospital, Nan Province
Since the number of diabetic patients has been dramatic increasing in Thailand year by year, so the
good medical care is needed for serving all patients requirement. In the present, the medical care for
diabetic patients in Pua district still has many problems.Most patients could not meet the standard outcomes on controlling the plasma glucose. This problem has been found to relate on the obstacle of transportation to DM clinic in hospital and the confidence in the service of intermediate facilities. The aim of
this research was to develop primary care for diabetic patient by Nurse Practitioner. The period of quasiexperimental research was started from 1st October 2010 to 30th September 2011. The study was focused
on the 418 patients that had well control of plasma glucose from 70 - 130 mg/dl and had level of HbA1C<
7%. The patients were divided into two groups. The first group was the 98 patients that received service at
the Subdistrict health promoting hospital. The second was the 320 patients that received service at Pua
Crown Prince Hospital. The result showed that the DM patients from Subdistrict health promoting hospital could control the level of plasma glucose better than those from Pua Crown Prince Hospital. The level
of HbA1c< 7% of the DM patients from primary medical care and Pua Crown Prince Hospital were 72.55%
and 54.37% respectively. In conclusion, the developing primary care for diabetic patient by Nurse Practitioner had found to be suitable for applying in Pua Contracting Unit Care. This concept is better to put
more effort and need simultaneous development for keeping fast track on the observation.
Keywords: Diabetes mellitus, Contracting Unit for Primary Care
* .
290
() .
.. .
.. .
..
.

- / ..

()

()

() ..

..
(fasting plasma glucose) ..()
.
() .. .

..()

.., .. ..
., . .
.
..
,
.. ,
.. ,
Fasting blood sugar

( - ./.)
HbA1c <%
()
()
..
..
..
.-.
.

.
..

(Seamless Health Service
Network)

..
(..)
.
..
..
. ..

(Quasi-experimental)()

.. .

.
(
- ./. HbA1C < %)

292
.
..
metformin, glibenclamide, glipizide, aspirin,
amlodipine, enalapril, simvastatin, gemfibrozil

...

.
..
fasting capillary blood glucose

(glucose meter)
(fasting plasma glucose)

HbA1c
..

..
.
Skype

Skype
.
. ..
..
.

.

( - ./. HbA1c
< % /
./.)
. ..
. ..
fasting capillary blood glucose
- ./.

Skype
.
()
(fasting
plasma glucose) HbA1c

monofilament

electrolyte

..

.

.-.

..
Fasting blood sugar

HbA1c < %

Chi - square
test SPSS
HbA1c
(..)
HbA1c
..

..
.
.
()
-
-
-
-
-

.
.
.
.
.
.
df
p-value
.
.
.
.
.
.
.
.

...
Fasting Blood Sugar (- ./.)

HbA1c <%
..
.
.

.
.
.

.
...
-
-
-
2
df
p-value

..
.
.
.
294
<.
HbA1c ...
..
.
HbA1c < %
.
.
HbA1c > %
.
.
df
p-value
(FBS) ..
.
..
.
Fasting blood
sugar - mg/dl
.
.
Fasting blood
sugar > mg/dl
.
.
df
p-value
df
p-value
...
..
.
.
.
(FBS)

(.. )

.
.
()
Skype

.-.
()

(swing
of asymptomatic and symptomatic event )()

(Cycle of hope and despair)
(
)
(FBS)
()
HbA1c ..

HbA1c
(FBS) HbA1c -
()

..

..
296
.

.
..
. . . : ,
, . Ambulatory Medicine. .
: ; .
-.
. WHO Ecobat NCD Info Base (NCD Info Base), 11 MAY 2004.
. Report of the second National Health Examination Survey in
1997. Thai Health Research Institute. Ministry of Public Health,
Bangkok; 2000.
. , , ,
, , .
..
-.. : ;
. .
. . NCD
; .
. , , , .
.
. : ; .-.
. . . .
: ; . .
. .
. : ,
(). . .
. ; .
-.
. . . :
. . :
; .
. .
(CUP) .
;:-.
. . .
;:-.
. , .
.
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. , , .
. .
: ; .

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