Malaysian Statistics on MEDICAL DEVICES 2007

Malaysian Statistics On MEDICAL DEVICES 2007

Ariza Zakaria Faridah Aryani Md. Yusof Lim T.O.

Subramani V; Mohammad Ali K; Mohd. Roslan H; Jahizah H; Zakaria Z; Ramanathan R; Katijjahbe M.A; Muralitharan G; Suganthi C; Suarn Singh; Aizai A; Abdul Razak M; Rosemi S; Zaki Morad; Murali S; Rohna R; Rahmat O; Mariam I.

A publication of the A publication of the Engineering Services Division, Medical Device Bureau and the Clinical Research Centre Ministry of Health Malaysia Engineering Services Division, Medical Device Bureau and the Clinical Research Centre Ministry of Health Malaysia Malaysian Statistics On MEDICAL DEVICES 2007

Ariza Zakaria Faridah Aryani Md. Yusof Lim T.O.

A publication of the Engineering Services Division, Medical Device Bureau and the Clinical Research Centre Ministry of Health Malaysia Malaysian Statistics On MEDICAL DEVICES 2007

Ariza Zakaria Faridah Aryani Md. Yusof Lim T.O.

A publication of the Engineering Services Division, Medical Device Bureau and the Clinical Research Centre Ministry of Health Malaysia Malaysian Statistics On Medical Devices 2007 August 2008 © Ministry of Health Malaysia

Published by: The National Medical Device Survey Level 3, MMA House 124, Jalan Pahang 53000 Kuala Lumpur Malaysia

Tel. : (603) 4043 9300 Fax : (603) 4043 9500 e-mail : [email protected] Web site: http://www.crc.gov.my/nmds

This report is copyrighted. However it may be freely reproduced without the permission of the National Medical Device Survey. Acknowledgement would be appreciated. Suggested citation is Ariza Z, Faridah A, Lim T.O. (Eds). Malaysian Statistics On Medical Devices 2007. Kuala Lumpur 2008

This report is also published electronically on the website of the National Medical Device Survey at: http://www.crc.gov.my/nmds

Funding: The National Medical Device Survey is funded by a grant from the Ministry of Health Malaysia (MRG Grant Number MRG-CRC-2008-02) FOREWORD

The Ministry of Health Malaysia has embarked on a landmark project, the National Medical Device Survey (NMDS), to capture data on the availability and use of medical devices in both the government and private sectors in Malaysia and this report is an output of the project.

This NMDS report is very relevant in the present environment of ever increasing healthcare costs in both the government and private sectors. We are almost completely lacking in data on the availability and use of medical devices in the country. This publication will help in some ways to rectify the situation.

I am confident this publication will be a very useful reference to the government, the industry and the public and I must congratulate those who are involved in the survey for successfully completing the project. I am looking forward to see that the data are regularly updated through follow-up surveys.

Y. BHG. DATUK IR. M.S. PILLAY Deputy Director General of Health, Research & Technical Support, Ministry of Health Malaysia

PREFACE

Data on the availability and use of medical devices is important to better understand healthcare provision in a country. Availability and access to medical technologies are likely to differ among countries and almost certainly unevenly distributed within a country. These differences could be because of several factors, such as demographic differences, differences in epidemiology of disease, differences in medical approaches or differences in economic conditions. This type of information allows for better decision-making in the allocation of resources and procurement of medical technologies. The use of this information can help to ensure access to and appropriate use of medical technology for better health outcomes.

To our knowledge, there has not been any published survey on the availability and utilization of medical devices in Malaysia and this aptly called National Medical Device Survey (NMDS) is, we believe, the first of its kind. However in carrying out this survey, in a country like Malaysia that does not have single central database on the procurement or reimbursement for medical devices, the task of compiling data on devices are fraught with problems. Data needed to be collected from multiple sources and some of these sources were less than forthcoming in providing data due to apprehension on the actual or possible use of the data or possibly, some sources were too busy to be able or want to provide the data needed.

After the hurdle of data collection was surmounted, the next problem was data analysis. There was a need for intelligent and expert analysis to distill credible information out of all these data as the data from various sources were not always complete or clean or in the format or depth that was wanted. We therefore regard this first report from the NMDS as a proof of concept; it demonstrates such project is indeed feasible. These initial efforts and experiences in conducting NMDS will stand us in good stead. NMDS is a work in progress, and as it improves its coverage and secure better cooperation from all relevant source data providers over time, we expect to publish more comprehensive reports in future.

We would like to thank all staff that has worked so hard in this survey. We would also like to thank all agencies and institutions who have helped in providing data and who have helped in one way or another.

Dr. Lim Teck Onn Mr. Zamane Abd. Rahman Mr. Chin Goo Chai Chairperson Co-Chairperson Co-Chairperson

National Medical Device Survey, Ministry of Health, Malaysia

iii ACKNOWLEDGEMENTS

The National Medical Device Survey would like to thank the following :

• All the medical doctors, medical assistants and nurses who participated in NMDS survey

• Participating private hospitals for cooperating with the survey

• The Faber Mediserve Sdn. Bhd., Radicare Sdn. Bhd. and Tongkah Medivest Sdn. Bhd., for their valuable assistance

• All who have in one way or another supported and/or contributed to the success of the NMDS and to this report

iv PARTICIPANTS OF THE NATIONAL MEDICAL DEVICE SURVEY MOH Hospitals 1. Hospital Alor Gajah 67. Hospital Muadzam Shah 2. Hospital Ampang 68. Hospital Mukah 3. Hospital Bahagia 69. Hospital Papar 4. Hospital Balik Pulau 70. Hospital Parit Buntar 5. Hospital Baling 71. Hospital Pasir Mas 6. Hospital Banting 72. Hospital Pekan 7. Hospital Batu Gajah 73. Hospital Permai 8. Hospital Batu Pahat 74. Hospital Pontian 9. Hospital Bau 75. Hospital Port Dickson 10. Hospital Beaufort 76. Hospital Pulau Pinang 11. Hospital Beluran 77. Hospital Putrajaya 12. Hospital Bentong 78. Hospital Queen Elizabeth 13. Hospital Besut 79. Hospital Raja Perempuan Zainab II 14. Hospital Betong 80. Hospital Rajah Charles Brooke Memorial 15. Hospital Bintulu 81. Hospital Ranau 16. Hospital Bukit Mertajam 82. Hospital Raub 17. Hospital Changkat Melintang 83. Hospital Saratok 18. Hospital Daro 84. Hospital Umum Sarawak 19. Hospital Duchess of Kent 85. Hospital Sarikei 20. Hospital Dungun 86. Hospital Seberang Jaya 21. Hospital Gerik 87. Hospital Segamat 22. Hospital Gua Musang 88. Hospital Selama 23. Hospital Hulu Terengganu 89. Hospital Selayang 24. Institute of Respiratory Medicine 90. Hospital Semporna 25. Hospital Ipoh 91. Hospital Sentosa 26. Hospital Jasin 92. Hospital Serdang 27. Hospital Jelebu 93. Hospital Seri Manjung 28. Hospital Jeli 94. Hospital Serian 29. Hospital Jempol 95. Hospital Setiu 30. Hospital Jengka 96. Hospital Sibu 31. Hospital Jerantut 97. Hospital Sik 32. Hospital Jitra 98. Hospital Simunjan 33. Hospital Kajang 99. Hospital Sipitang 34. Hospital Kampar 100. Hospital Slim River 35. Hospital Kanowit 101. Hospital Sri Aman 36. Hospital Kapit 102. Hospital Sultan Abdul Halim 37. Hospital Kemaman 103. Hospital Sultan Haji Ahmad Shah 38. Hospital Keningau 104. Hospital Sultan Ismail 39. Hospital Kepala Batas 105. Hospital Besar Sultanah Aminah 40. Hospital Kinabatangan 106. Hospital Sultanah Bahiyah 41. Hospital Kluang 107. Hospital Pakar Sultanah Fatimah 42. Hospital Kota Belud 108. Hospital Sultanah Nur Zahirah 43. Hospital Kota Marudu 109. Hospital Sungai Bakap 44. Hospital Kota Tinggi 110. Hospital Sungai Buloh 45. Hospital Kuala Kangsar 111. Hospital Sungai Siput 46. Hospital Kuala Krai 112. Hospital Taiping 47. Hospital Kuala Kubu Bharu 113. Hospital Tambunan 48. Hospital Kuala Lipis 114. Hospital Tampin 49. Hospital Kuala Lumpur 115. Hospital Tanah Merah 50. Hospital Kuala Nerang 116. Hospital Tangkak 51. Hospital Kudat 117. Hospital Tanjong Karang 52. Hospital Kulim 118. Hospital Tapah 53. Hospital Kunak 119. Hospital Tawau 54. Hospital Labuan 120. Hospital Teluk Intan 55. Hospital Lahad Datu 121. Hospital Temenggung Seri Maharaja Tun Ibrahim 56. Hospital Langkawi 122. Hospital Tengku Ampuan Afzan 57. Hospital Daerah Lawas 123. Hospital Tengku Ampuan Jemaah 58. Hospital Likas 124. Hospital Tengku Ampuan Rahimah 59. Hospital Limbang 125. Hospital Tengku Anis 60. Hospital Daerah Lundu 126. Hospital Tenom 61. Hospital Machang 127. Hospital Tuanku Ampuan Najihah 62. Hospital Marudi 128. Hospital Tuanku Fauziah 63. Hospital Melaka 129. Hospital Tuanku Ja’afar 64. Hospital Mersing 130. Hospital Tuaran 65. Hospital Mesra Bukit Padang 131. Hospital Tumpat 66. Hospital Miri 132. Hospital Yan

University & Armed Forces Hospitals 1. Pusat Perubatan Universiti Kebangsaan Malaysia 2. Pusat Perubatan Universiti Malaya 3. Hospital Universiti Sains Malaysia 4. Hospital Angkatan Tentera Lumut 5. Hospital Angkatan Tentera Terendak

Private Hospitals 1. Amanjaya Specialist Centre 42. National Heart Institute 2. Arunamari Specialist Medical Centre 43. NCI Cancer Hospital 3. Assunta Hospital 44. Normah Medical Specialist Centre 4. Az-Zahrah Islamic Medical Centre 45. Pantai Ayer Keroh Hospital Sdn. Bhd 5. Bukit Mertajam Specialist Hospital 46. Pantai Cheras Medical Centre 6. Columbia Asia Medical Centre, Sarawak 47. Pantai Indah Hospital 7. Columbia Asia Medical Centre, Seremban 48. Pantai Mutiara Hospital 8. Columbia Asia Nursing and Rehabilitation Centre 49. Peace Medical Centre 9. Damai Medical and Heart Clinic Sdn. Bhd 50. Pelangi Medical Centre 10. Damai Service Hospital (Head Quarters) 51. Penang Adventist Hospital 11. Damai Specialist Centre Sdn. Bhd 52. Penawar Hospital 12. Damansara Specialist Hospital 53. Perak Community Specialist Hospital 13. Darul Ehsan Medical Centre 54. Perdana Specialist Hospital 14. Gleneagles Medical Centre, Penang 55. Pusat Pakar Tawakal 15. Hope Children Hospital, Farlim 56. Pusat Rawatan Islam Medical Centre 16. Hope Children Hospital, Jln Gottlieb 57. PUSRAWI Hospital Sdn. Bhd 17. Hope Children Hospital, Sg. Ara 58. PUSRAWI SMC Hospital Sdn. Bhd 18. INS Specialist Centre 59. Puteri Specialist Hospital 19. Ipoh Specialist Hospital 60. Putra Medical Centre, Alor Setar 20. Island Hospital 61. Putra Medical Centre, Sungai Buloh 21. Johor Specialist Hospital 62. Putra Specialist Hospital (Melaka) Sdn. Bhd 22. Kajang Medical Centre 63. Rafflesia Medical Centre Sdn. Bhd 23. Kajang Plaza Medical Centre 64. Rejang Medical Centre 24. Kampung Baru Medical Centre 65. Sabah Medical Centre 25. KCDC Hospital Sdn. Bhd 66. Sambhi Clinic Sdn. Bhd 26. Kedah Medical Centre 67. Sentosa Medical Centre (KPJ Kajang Specialist Hosp.) 27. Kempas Medical Centre 68. Siow Specialist Hospital 28. Kinta Medical Centre 69. Sri Kota Specialist Medical Centre 29. Kota Bharu Medical Centre 70. Sri Manjung Specialist Centre Sdn. Bhd 30. Kuantan Medical Centre 71. Srigim Specialist Women and Children’s Hospital 31. Lam Wah Ee Hospital 72. Subang Jaya Medical Centre 32. Landmark Medical Centre Sdn. Bhd 73. Sunway Medical Centre 33. Larut Medical Centre 74. Taiping Medical Centre 34. Loh Guan Lye Specialist Centre 75. Taj Hospital 35. Mahkota Medical Centre 76. Taman Desa Medical Centre 36. Medical Specialist Centre (JB) Sdn. Bhd 77. Tanjung Medical Centre 37. Metro Specialist Hospital 78. Timberland Medical Centre 38. Miri City Medical Centre 79. Tun Hussein Onn National Eye Hospital 39. Mount Miriam Hospital Cancer Centre 40. Multimedic Specialist & Maternity Centre 41. N. S. Chinese Maternity Hospital and Medical Centre

vi About the National Medical Device Survey The National Medical Device Survey (NMDS) is a service initiated and supported by the Ministry of Health (MOH) to collect information on the supply, procurement and utilization of medical devices in Malaysia. It is designed to quantify the current trends of availability and utilization of medical devices, as well as support the implementation of the proposed regulatory system for medical devices in Malaysia. In supporting this, the NMDS shall provide the functional capacity for the collection, analysis, reporting and dissemination of data on medical devices in Malaysia.

Sponsors and Organization of the NMDS The NMDS is jointly sponsored by: • The Engineering Services Division and the Medical Device Bureau of the MOH • The Clinical Research Centre, National Institute of Health MOH.

The Pharmaceutical Research Unit of the Clinical Research Centre MOH undertakes the daily operation of NMDS. To ensure that the NMDS meets the needs and expectations of all interested parties, a Governance Board has been established to oversee the operations of the NMDS. All major groups involved in medical device issues in Malaysia such as the MOH, professional bodies, private healthcare providers and the medical device industries are represented on this board. The board, therefore works as a consultative forum and provide advice on issues pertaining to the NMDS and other aspects of quality use of medical devices in Malaysia.

Premise of the NMDS Efficient functioning of device market depends in part on buyers’ access to information on suppliers, products and prices. Safe and effective use of device depends in part on users’ access to information on technical performance and users’ instructions. The objective of the NMDS is therefore to quantify the present state and time trends of medical device procurement and utilization at various level of our health care system, whether national, regional, local or institutional. It will provide a public information service to ensure that high quality, reliable and timely information on medical devices are available for promoting equitable access to, and safe and effective use of such devices in Malaysia.

Routinely compiled statistics on availability and use of medical devices have many applications, such as to: 1. Describe the demographic patterns of device availability and utilization to better understand device use in its natural clinical environment. 2. Estimate expenditure on medical devices, which constitutes a significant proportion of our public and private healthcare costs. 3. Monitor and evaluate the cost-effectiveness of device-based treatments with respect to device productivity and equity in provision, which may have significant impact on resource management within our healthcare system. 4. Monitor users’ device-experience and evaluate the clinical effectiveness of medical devices, and their associated health outcomes as well as factors influencing those outcomes. 5. Support reporting of adverse events or product problems by suppliers or user facilities. 6. Relate the number of adverse device effects reported to our device vigilance system to the number of people exposed to the device in order to assess the magnitude of the problem, or to estimate the degree of under-reporting of adverse events. 7. Stimulate and facilitate applied clinical and epidemiologic research on the economics, utilization, safety and effective use of medical devices.

vii NMDS Governance Board CHAIRPERSON: Dr. Lim Teck Onn, Director, Clinical Research Center MOH.

CO-CHAIRPERSON: Mr. Zamane Abdul Rahman, Director, Medical Device Bureau MOH.

CO-CHAIRPERSON: Mr. Chin Goo Chai. Director, Engineering Services Division MOH

MEMBERS Clinical Research Centre MOH Dr. Faridah Aryani Md. Yusof

Medical Device Bureau MOH Mr. Ahmad Sharif Hambali

Engineering Services Division MOH Pn. T. Sasikala Devi

Procurement Division MOH Pn. Hamidah Bidin

Malaysian Medical Association -

Malaysian Dental Association (MDA) -

Malaysian Private Dental Practitioner’s - Association (MPDPA)

Association of Private Hospitals Malaysia Dr. Hooshmana M Palany (APHM)

Malaysian Medical Device Association Mr. Yong Tuan Heng

Association of Malaysian Medical Mr. Peter Ring Industries

viii MEMBERS OF NMDS EXPERT PANELS Expert Panel Institution 1. Imaging and Diagnostic Facilities And Devices Dr. Subramani A/L Venugopal (Chairperson) Hospital Tuanku Ja’afar Dr. Nik Fatimah Salwati Hospital Sultanah Bahiyah Dr. Hjh Salwah Hashim Hospital Pulau Pinang Dr. Zaharah Musa Hospital Selayang. Dr. Harikrishna A/L Sivaganabalan Hospital Tengku Ampuan Rahimah Dr. Che Zubaidah Che Daud Institut Pediatrik, HKL. Ir. Dr. Syed Mustafa Kamal Engineering Services Div, MOH

2. Nuclear Medicine Facilities And Devices Dato’ Dr. Mohammad Ali Kadir (Chairperson) Hospital Pulau Pinang Dr. Lee Boon Nang Hospital Kuala Lumpur.

3. Oncology Facilities And Devices Dr. Mohd. Roslan Bin Haron (Chairperson) Hospital Sultan Ismail Ass. Prof. Dr. Fuad Ismail Pusat Perubatan Universiti Kebangsaan Malaysia Dr. Ahmad Kamal Mohamed Subang Jaya Medical Centre Dr. Vincent Phua Hospital Kuala Lumpur En. Mohd Farihan Jaffar Hospital Kuala Lumpur Puan Rubiah Mohd Pakah Hospital Kuala Lumpur Pn Mahzom Pawanchek Hospital Kuala Lumpur

4. Anaesthesiology and Intensive Care Facilities And Devices Dato’ Dr. Jahizah Hj. Hassan (Chairperson) Hospital Pulau Pinang Prof. Dr. Mazidar Mansor. Pusat Perubatan Universiti Malaya Clinical Ass. Prof. Dr. Choy Yin Choy. Pusat Perubatan Universiti Kebangsaan Malaysia Dato’ Dr. Teh Keng Hwang Hospital Sultanah Bahiyah Dr. Irene Cheah Hospital Kuala Lumpur Dr. Neoh Siew Hong Hospital Taiping

5. General Surgery Facilities And Devices Dato’ Dr. Zakaria Bin Zahari (Chairperson) Hospital Kuala Lumpur Dr. Mohammed Saffari Mohammed Haspani Hospital Kuala Lumpur Dr. Mohd Mazri Yahya Hospital Kuala Lumpur

6. Orthopedic & Traumatology Facilities And Devices Dato’ Dr. Ramanathan Ramiah (Chairperson) Hospital Ipoh Dr. Mohammad Anwar Hau Abdullah Hospital Raja Perempuan Zainab II Dr. Kamariah Nor Mohd Daud Hospital Kuala Lumpur Dr. Ng Yue Onn Hospital Ampang Dr. Lee Joon Kiong Pantai Medical Centre Bangsar Dr. Mahathar Abd Wahab Hospital Kuala Lumpur

ix 7. Physiotherapy and Occupational Therapy Facilities And Devices Cik Katijjahbe Mohd Ali (Chairperson) Pusat Perubatan Universiti Kebangsaan Malaysia Datin Hjh Asiah Bt Hashim Hospital Kuala Lumpur Pn. Misnah Roslam Hospital Serdang Pn. Tan Wai Choo Hospital Sungai Buloh Pn. Wong Swee Fong Hospital Tengku Ampuan Rahimah Pn. Lim Khee Li Hospital Kuala Lumpur Pn. Hjh. Hamidah Hj. Ariffin Hospital Selayang Pn. Khuzaimah Abd. Aziz Hospital Kuala Lumpur Pn. Jamaliah Musa, Hospital Kuala Lumpur Pn. Zalila Kashim Hospital Kuala Lumpur Pn Aqilah Leela T. Narayanan Hospital Sultanah Aminah Pn. Zunaidah Abu Samah Hospital Kuala Lumpur Pn. Tan Foo Lan Hospital Kuala Lumpur Pn Anil Kalsom Bte Musa Hospital Tengku Ampuan Rahimah Pn. Rohana Mukahar Pusat Perubatan Universiti Kebangsaan Malaysia Dr. Julia Patrick Engkasan Pusat Perubatan Universiti Kebangsaan Malaysia Pn. Noormah Mohd Darus Health Technology Assesment Div., MOH

8. Obstetrics & Gynecology Facilities And Devices Dr. Muralitharan Ganesalingam (Chairperson) Hospital Kuala Lumpur Dr. Zaridah Shaffie Hospital Tuanku Fauziah Dr. Krishnakumar A/L Harikrishnan Hospital Tuanku Ja’afar Dr. R.P Japaraj Hospital Ipoh

9. Neurology Facilities And Devices Dr. Suganthi Chinnasami Hospital Kuala Lumpur Y. Bhg. Dato’ Dr. Md. Hanip Bin Rafia Hospital Kuala Lumpur Dr. Santhi Datuk Puvanarajah Hospital Kuala Lumpur Dr. Mooi Chin Leong Hospital Kuala Lumpur

10 Psychiatry Facilities And Devices Dato’ Dr. Suarn Singh Hospital Bahagia Ulu Kinta Dr. Hj. Mohd Daud Dalip Hospital Mesra Bukit Padang Dr. Siti Nor Aizah Ahmad Hospital Kuala Lumpur. Prof Dr. Mohd Fadzillah Bin Abdul Razak Universiti Malaysia Sarawak En Rosdi Bin Zainol Hospital Kuala Lumpur Dr. Hj. Mohd Rasidi M. Saring Hospital Sultanah Bahiyah

11. Cardiology And Cardiothoracic Surgery Facilities And Devices Dr. Aizai Azan (Chairperson) Institut Jantung Negara Dr. Surinder Kaur Institut Jantung Negara Dr. Alan Yean Yip Fong Hospital Umum Sarawak Dr. Chong Wei Peng Pusat Perubatan Universiti Malaya Dr. Faisal Bin Ismail Hospital Serdang Dr. Ernest Ng Hospital Serdang Prof Dr. Sim Kui Hian Hospital Umum Sarawak Dr. Ong Tiong Kiam Hospital Umum Sarawak

12. Respiratory Medicine Facilities And Devices Dato’ Dr. Abdul Razak Abdul Mutalif Hospital Pulau Pinang Assoc. Prof. Dr. Roslina Abdul Manap Pusat Perubatan Universiti Kebangsaan Malaysia Dr. Tengku Saifudin Tengku Ismail Hospital Selayang Dr. Noor Aliza Md Tarekh Hospital Sultanah Aminah Dr. George Kutty Simon Hospital Sultanah Bahiyah Dr. Ashari Yunus Institut Perubatan Respiratori Dr. Jamalul Azizi Abdul Rahman Hospital Queen Elizabeth Dr. Norhaya Mohd Razali Hospital Sultanah Nur Zahirah Assoc. Prof. Dr. Pang Yong Kek Pusat Perubatan Universiti Malaya Assoc. Prof. Dr. How Soon Hin Universiti Islam Antarabangsa Malaysia / Hospital Tengku Ampuan Afzan Professor Dr. Liam Chong-Kin Pusat Perubatan Universiti Malaya Dr. Mat Zuki Bin Mat Jaeb Hospital Raja Perempuan Zainab II Dr. Zalwani Bt Zainuddin Hospital Tuanku Fauziah Bgd Gen Dr. Mohd Ello Mohd Sued Hospital Angkatan Tentera Lumut

13. Gastroenterology Facilities And Devices Dr. Hj. Rosemi Salleh (Chairperson) Hospital Raja Perempuan Zainab II Dato’ Dr. Muhammad Radzi Abu Hassan Hospital Sultanah Bahiyah Dr. Hjh Rosaida Hj Md Saudi Hospital Kuala Lumpur Dr. Sheikh Anwar Abdullah Pusat Perubatan Universiti Kebangsaan Malaysia

14. Nephrology Facility And Devices Prof. Dato’ Dr. Zaki Morad (Chairperson) Ampang Puteri Specialist Hospital Dr. Ong Loke Meng Hospital Pulau Pinang Dato’ Dr. Rozina Ghazalli Hospital Pulau Pinang Dr. Hooi Lai Seong Hospital Sultanah Aminah Dr. Goh Bak Leong Hospital Serdang Dr. Lim Yan Ngo Hospital Kuala Lumpur Tn. Hj. Mohd Sulaiman Bin Dalimi Hospital Serdang En. A. Suhaili Bin Shahri Hospital Kuala Lumpur Sr Lee Day Guat National Renal Registry

xi 15. Urology Facilities And Devices Dr. Murali Sundram Abdullah (Chairperson) Hospital Kuala Lumpur Dr. Clarence Lei Chang Moh Normah Medical Centre

16. Dermatology Facilities And Devices Dr. Rohna Ridzwan (Chairperson) Hospital Selayang Puan Sri Datin Dr. Suraiya Hani Tun Hussein. Hospital Kuala Lumpur Dr. Asmah Johar Hospital Kuala Lumpur Dr. Choon Siew Eng Hospital Sultanah Aminah, Johor Bahru Dr. Najeeb Bin Mohd. Safdar Hospital Tuanku Jaafar

17. Otorhinolaryngology And Audiology Facilities And Devices Prof. Madya Dr. Rahmat Omar (Chairperson) Pusat Perubatan Universiti Malaya Dato’ Dr. Abd. Majid Md. Nasir Hospital Kuala Lumpur Dr. Junainah Sabirin Health Technology Assesment Div., MOH En. Mahamad Almyzan Awang Pusat Perubatan Universiti Kebangsaan Malaysia Cik Nor Shahrina Mohd Zawawi Pusat Perubatan Universiti Kebangsaan Malaysia

18. Ophthalmology And Optometry Facilities And Devices Datin Dr. Mariam Ismail (Chairperson) Hospital Selayang Dr. Goh Pik Pin Hospital Selayang Dato’ Dr. Balaravi Pillai Hospital Ipoh Dato’ Dr. Vasantha Kumar S. Thangasamy Hospital Tengku Ampuan Rahimah Dr. Hj. Abdul Mutalib Bin Othman Hospital Queen Elizabeth Dr. Jamalia Rahmat Hospital Kuala Lumpur

xii NMDS Project Staff Project Leader Dr. Faridah Aryani Md. Yusof

Clinical Research Manager Dr. Ariza Zakaria.

Clinical Research Coordinator -

Research Assistants -

Economist Mr. Adrian Goh

Statistician Dr. Hoo Ling Ping

IT Manager Ms. Celine Tsai Pao Chien

Database Developer/ Administrator Ms Tang Roh Yu Mr. Patrick Lum See Kai

Network Administrator Mr. Kevin Ng Hong Heng Mr. Adlan Abd. Rahman

Desktop Publisher & Webmaster Ms. Azizah Alimat

xiii

CONTENTS

FOREWORD i Preface iii Acknowledgements iv Participants Of The National Medical Device Survey v About The National Medical Device Survey vii NMDS GOVERNANCE BOARD viii Members Of NMDS Expert Panels ix NMDS Project Staff xiii Contents xv ABBREVIATIONS xvi METHODS xvii Chapter 1: Imaging And Diagnostic Facilities And Devices 1 Chapter 2: Nuclear Medicine Facilities And Devices 5 Chapter 3: Oncology Facilities And Devices 9 Chapter 4: Anaesthesiology And Intensive Care Facilities And Devices 11 Chapter 5: General Surgery Facilities And Devices 15 Chapter 6: Orthopaedic And Traumatology Facilities And Devices 21 Chapter 7: Physiotherapy And Occupational Therapy Facilities And Devices 23 Chapter 8: Obstetrics & Gynaecology Facilities And Devices 27 Chapter 9: Neurology Facilities And Devices 31 Chapter 10: Psychiatry Facilities And Devices 35 Chapter 11: Cardiology And Cardiothoracic Surgery Facilities And Devices 39 Chapter 12: Respiratory Facilities And Devices 43 Chapter 13: Gastroenterology Facilities And Devices 47 Chapter 14: Nephrology Facilities And Devices 53 Chapter 15: Urology Facilities And Devices 57 Chapter 16: Dermatology Facilities And Devices 63 Chapter 17: Otorhinolaryngology And Audiology Facilities And Devices 69 Chapter 18: Ophthalmology And Optometry Facilities And Devices 73 Chapter 19: Gaps In Medical Technology In Malaysia 79

xv ABBREVIATIONS

ABBI Advanced Breast Biopsy Instrumentation NCV Nerve Conduction Velocity APC Argon Plasma Coagulation NCS Nerve Conduction Study BAER Brainstem Auditory Evoked Response ND No Data BER Beyond Economic Repair Nd:YAG Neodymium-Doped Yttrium Aluminium Garnet BiPAP Bilevel Positive Airway Pressure NMDS National Medical Device Survey Cathlab Cardiac Catheterization Laboratory OAE Otoacoustic Emission CCU Coronary Care Unit ORL Otorhinolaryngology COPD Chronic Obstructive Pulmonary Disease PCA Patient Controlled Analgesia CPAP Continuous Positive Airway Pressure PD Peritoneal Dialysis CPM Continuous Passive Motion PET Positron Emission Tomography CRC Clinical Research Centre PICU Paediatric Intensive Care Unit CRRT Continuous Renal Replacement Therapy PSG Polysomnography CT Computed Tomography PUVA Psoralen combined with exposure to ultraviolet CTG Cardiotocography light A (UVA) CUSA Cavitron Ultrasonic Surgical Aspirator SDP Source Data Providers DBE Double Balloon Enteroscope SSEP SomatoSensory Evoked Potential DG Director General of Health, Ministry of Health, SWD Short Wave Diathermy Malaysia TCD Transcranial Doppler ECG Electrocardiography TEE Trans-Oesophageal Echocardiography ECMO Extra-Corporeal Membrane Oxygenator TENS Transcutaneous Electrical Nerve Stimulation ECT Electroconvulsive Therapy UVA Ultraviolet light A EEG Electroencephalography UVB Ultraviolet light B EMG Electromyography VACS Vacuum Assisted Closure System EOG Electrooculography VEP Visual Evoked Potential EP Evoked Potential VT Video-Telemetry ESWL Extracorporeal Shockwave Lithotripter WHO World Health Organization EUS Endoscopic Ultrasound FESS Functional Endoscopic Sinus Surgery GB Governance Board HAL Haemorrhoid Artery Ligation HD Haemodialysis HDU Haemodialysis Unit HFOV High Frequency Oscillatory Ventilator HKL Kuala Lumpur Hospital HDR High Dose-Rate IABP Intra-Aortic Balloon Pump ICU Intensive Care Unit IMRT Intensity Modulated Radiotherapy IVUS Intra Vascular Ultrasound KKM Kementerian Kesihatan Malaysia LINAC Linear Accelerator LDR Low Dose-Rate LVAD Left Ventricular Assist Device MDB Medical Device Bureau MMHD Malaysian Medical Health Directory MOH Ministry of Health MRI Magnetic Resonance Imaging NC Not Classified (cannot be classified between public and private sectors)

xvi METHODS Introduction The NMDS is designed, broadly speaking, to estimate the quantity and pattern of use of medical devices in Malaysia, as well as to estimate our expenditure on devices. This is an ambitious project, which requires multiple surveys targeting the various levels of the medical device supply chain and utilization in healthcare facilities in the country in order to capture all the required data to meet its purpose. For this first effort, we had therefore realistically targeted data sources that are absolutely critical and accessible.

Hence, the statistics on the availability of medical device in this report are estimated based on data from only a limited number of surveys. In particular, the scope of the survey was limited to: • Hospitals only, though for certain therapy areas (Nephrology, Cardiology), we were able to supplement the data from more specialized surveys conducted by the National Renal Registry (NRR) and National Cardiovascular Disease Database (NCVD) • Asset device only. Data on disposable devices will have to await future survey.

Survey Population, Sampling And Response (Coverage) Rate The survey conducted by NMDS and supplemented by those by NRR and NCVD, its survey population, its sampling unit and sample size, and the survey response or coverage rates are summarized in the table below.

# Site Classification Survey population MaximumResponse Minimum Response Rate (%) Rate (%)

1. Public sector 137 71 43

2 Private sector 79 55 37

* Note: 1. Public sector consists of 132 MOH, 3 University and 2 Armed Forces hospitals. 2. Response rates vary between specialties.

The survey conducted by NMDS and supplemental surveys by NRR and NCVD were entirely by primary data collection. For MOH data, available database on device asset was also used to cross- check the data.

Data Management The collected data, whether in databases, on paper or electronic data collection form, is compiled into a single database, appropriately processed and coded prior to statistical analysis.

The database server is running on a Windows 2000 Server. The server environment is Intel Xeon 2.4 Mhz, with a total of 2GB RAM memory and 67.8GP Raid5 Hard disk. The NMDS database was created in Ms SQL Server 2000. The application has 3 modules: Contact Management, Data Entry and Data Processing.

xvii The data processing steps for this initial version of NMDS data are presented as follows, in 2 phases:

Phase 1 Survey/Database Development and Data Collection

1. On the basis of the NMDS project’s Terms of Reference (ToR), some initial discussions were held within CRC, supplemented with research on literature to develop the first drafts of NMDS survey forms.

2. Various existing databases were obtained and studied to extract learnings for application on the NMDS. Where relevant, these learnings were used to enhance/edit the structure and content of survey forms.

3. On the basis of the said information in 1 & 2, the first draft of the survey forms were produced and presented for challenge of adequacy in the required data fields/ variables for each specialty.

4. Draft survey forms were shared with internal and external referees and the feedback was collated for the finalization of the survey forms. In most cases, the project team had to consult with the experts in various disciplines to get a better understanding of the variables of significance.

5. The survey forms were then finalized for approval, with the final versions being made up of 28 medical specialties and 5 supportive specialties.

The variables required were divided into 3 sections: Section 1: Establishment Details. Section 2: Diagnostic and Therapeutic Facility. Section 3: Associated Equipment of Interest.

6. Approval of the NMDS survey was granted by the Chairperson of the NMDS, allowing the team to proceed with actualizing the survey activities.

7. The approved survey forms were shared with the IT department for them to use as the basis for creating the NMDS Database. The intention was for the Database to be ready for populating by the time the completed survey forms had been returned by the SDPs.

8. Upon approval, survey forms were sent out to the Directors of relevant identified SDPs to seek voluntary participation into the survey. SDPs were identified from the Malaysian Medical Health Directory (MMHD) and counter-checked by staff making the calls.

9. The project team was dependent on the SDP sites to ensure the survey forms were appropriately distributed within their institutions. The project team then followed up with each individual specialty. The follow up was dependent on the availability of the specialty at the site with the MMHD used as reference. Where there are uncertainties, the NMDS project team contacts the SDP directly to ascertain the availability of specialties. A “service provider” of a particular specialty was defined as any participating site that provides specialists services respective to the discipline and includes sites that only provide visiting specialist services. It does not require a resident specialist to be available at the site.

10. SDPs are meant to respond within a set deadline. Feedback is received either by fax or post prior to Data processing. The NMDS project team also takes the initiative to pursue timely feedback from the respondents.

xviii Data Processing of Survey Data

1. Survey data was entered into the NMDS Database that had been created by the IT department based on the finalized survey forms (refer to Phase 1: 7 above). Drop down options similar to that in the survey form of each specialty was part of the database design to minimize data entry errors. Prior to data entry, personnel were fully briefed on how to use the database and enter the data via a training event which included a demonstration.

Personnel were supervised whilst doing the first few entries to make sure sufficient competency had been developed to minimize if not eliminate errors.

A standard document on steps and precautions on Data entry was mailed to each personnel. Those who were unable to decipher the feedback were advised to enquire from senior staff.

Each entry is recorded for quality assurance purposes.

2. Visual review and manual assessment of entries are performed to capture erroneous, inconsistent or inaccurate entries in the survey forms. These typically occur when information is entered under the “Others” or “Shared Equipment” section. Follow-up with the SDP is performed where required.

Where data was provided using brand names, online searches or follow-up with the SDP was conducted to guide any required editing of the survey form data.

3. The populated Database then underwent Edit Checks, with the database entries being meticulously crosschecked against the original survey forms.

4. It was then decided to exclude further data processing of a subset of devices reported by the SDPs due to limitations in resources. The criteria for selection of devices to be reported per specialty were outlined by priority for treatment and quality of survey data available. Selection was done by the NMDS project team with support from the Chairperson.

Only data on functioning medical devices were processed and reported. Functioning medical devices were defined as medical equipment that were used in daily procedures at the participating site and excludes: • equipment deemed as in Beyond Economic Repair as well as • equipment which, although were still in working condition, were non-operational (not used) at the site.

5. Data is then exported to Datamed Bio-Statistics for further data processing.

This included a specific focus on estimation of missing data from poorly populated survey forms or non-responsiveness.

Datamed personnel were tasked with grouping and collating the NMDS data into forms and reports that would allow further study by the project team. These forms and reports were used by the team to assess the quality of the NMDS data internally as well as with assistance from the expert panel.

xix Statistical Methods In this report, the quantity of the availability of a device is expressed as in absolute count as well as in number per million inhabitants. The latter statistics are calculated as follows:

T Number of device/million population = P

Where T is an estimate of the total quantity of the device available in the country in the year under consideration P is the mid-year population of Malaysia or the relevant geographic region where the survey was conducted

T the total is estimated from the sample of relevant health care facilities as follows:

The total is estimated by T = Σ Wi Ti

Where; th Ti is the value of the quantity of device available in the i facility in the year

th Wi is the sampling weight of the i facility

Wi = (B/b) * (bi/ Ь)

Where B is total number of beds in the population, b is number of beds of the responding hospitals th (sample), bi is number of beds in the i facility, and Ь the mean number of beds in the population. The sampling weight for each sampling unit or unit of analysis therefore has the following components:

1. Probability of selection. The basic weight is obtained by multiplying the reciprocals of the probability of selection at each step of sampling design.

2. Adjustment for non-response. The response rate was less than 100% for hospital surveys; an adjustment to the sampling weight is required. The non-response adjustment weight is a ratio with the number of units in the population as the numerator and the number of responding sampling units as the denominator. The adjustment reduces the bias in an estimate to the extent that non-responding units have same characteristics as responding units. Where this is unlikely, some adjustments took into account differences in some relevant characteristics between responding and non-responding units that may influence drug utilization, such as bed strength, staff strength, scope of services for hospitals etc.

Finally, adjustments are also made to the statistical estimates to approximate known values from existing device asset database and from key informants, where these are available.

xx CHAPTER 1 IMAGING AND DIAGNOSTIC FACILITIES AND DEVICES

Edited by : Dr. Subramani a/l Venugopal1

With contributions from : Dr. Che Zubaidah Che Daud2, Dr. Harikrishna a/l Sivaganabalan3, Dr. Hjh. Salwah Hashim4, Dr. Nik Fatimah Salwati5, Dr. Zaharah Musa6

1 Hospital Tuanku Ja’afar, 2 Hospital Kuala Lumpur, 3 Hospital Tengku Ampuan Rahimah, 4 Hospital Pulau Pinang, 5 Hospital Sultanah Bahiyah, 6 Hospital Selayang

REPORT The National Medical Devices Survey (NMDS), a service initiated and supported by the Ministry of Health, and coordinated by the CRC, gives complete information on the availability of devices and services in all states in Malaysia. This information is crucial for future planning and financing of equipment and manpower.

The current survey can be considered a good starting point, but some minor changes will be made for future data collection, in order to better reflect the Imaging and Diagnostic facilities, equipment and services that are available. Accurate compilation of data in this NMDS survey will greatly facilitate the planners to buy the right thing for the right place at the right time.

With capital expenditure for Imaging and Diagnostic being very high, coupled with rapid advances in technology, it is imperative that we have accurate records of the devices available, so that they can be optimally utilized, with minimal or no duplication of services, for a given population.

Almost all larger hospitals (both public and private) in the country are now fairly well equipped with general radiography, fluoroscopy, ultrasound, mammography, computed tomography (CT) and magnetic resonance scanners. Angiography services are available in most tertiary centers. Basic and vascular interventional radiology is fast developing into a necessity. Smaller or primary hospitals and health facilities are also fairly well equipped with radiological services commensurate with the clinical services provided.

However, the rapid explosion of technology has thrown so many new machines and techniques, which need careful evaluation, before being adopted in Malaysia.

This report is done with the data provided by the contributors from all states. Some of the states cannot obtain accurate data from all hospitals, especially in the private hospitals.

Table 1: Available Therapeutic and Diagnostic Facilities in Imaging and Diagnostic Medicine Population Radiology Centre No in million No % pmp Malaysia 26.64 108 100 4

Sector Public - 66 61 Private - 42 39

State Johor 3.17 9 8 3 Kedah & Perlis 2.11 7 6 3 Kelantan 1.53 7 6 5 Melaka 0.73 5 5 7 Negeri Sembilan 0.96 2 2 2 Pahang 1.45 7 6 5 Perak 2.28 11 10 5 Terengganu 1.04 3 3 3 Pulau Pinang 1.49 11 10 7 Sabah 3 13 12 4 Sarawak 2.36 12 11 5 Selangor & W.P. Kuala Lumpur 6.43 21 19 3

Table 2: Available Medical Devices in Imaging and Diagnostic Medicine Magnetic Computed Resonance Angiographic Mobile C-Arm Population Tomography (CT) Imaging (MRI) Unit Unit Scanner Unit No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 100 100 4 63 100 2 42 100 2 250 100 9

Sector Public - 51 51 31 49 17 40 152 61 Private - 49 49 32 51 25 60 98 39

State Johor 3.17 7 7 2 5 8 2 3 7 1 16 6 5 Kedah & 2.11 7 7 3 6 9 3 3 7 1 18 8 9 Perlis Kelantan 1.53 3 3 2 2 3 1 2 5 1 11 4 7 Melaka 0.73 5 5 7 4 6 5 3 7 4 9 4 12 Negeri 0.96 3 3 3 2 3 2 2 5 2 8 3 8 Sembilan Pahang 1.45 4 4 3 2 3 1 1 2 1 11 4 8 Perak 2.28 6 6 3 4 6 2 2 5 1 22 9 10 Terengganu 1.04 1 1 1 1 2 1 0 0 0 8 3 8 Pulau Pinang 1.49 14 14 9 8 13 5 7 16 5 28 12 19 Sabah 3 7 7 2 3 5 1 2 5 1 11 4 4 Sarawak 2.36 11 11 5 5 8 2 3 7 1 21 8 9 Selangor & W.P 6.43 32 32 5 21 33 3 14 33 2 87 35 14 Kuala Lumpur

Mammography Total Conventional Digital Population with Stereotactic Mammography Mammography Mammography Biopsy System

No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 95 100 4 37 100 1 9 100 0 37 100 1

Sector Public - 48 51 10 27 2 22 27 73 Private - 47 49 27 73 7 78 10 27

State Johor 3.17 9 9 3 3 8 1 0 0 0 5 13 2 Kedah & Perlis 2.11 7 7 3 1 3 0 1 11 0 4 11 2 Kelantan 1.53 2 2 1 1 3 1 0 0 0 1 3 1 Melaka 0.73 4 4 5 4 11 5 0 0 0 0 0 0 Negeri Sembilan 0.96 4 4 4 2 5 2 0 0 0 1 3 1 Pahang 1.45 4 4 3 2 5 1 0 0 0 1 3 1 Perak 2.28 8 8 4 3 8 1 0 0 0 4 11 2 Terengganu 1.04 1 1 1 0 0 0 0 0 0 1 3 1 Pulau Pinang 1.49 12 13 8 5 14 3 1 11 1 5 13 3 Sabah 3 6 6 2 2 5 1 1 11 0 3 8 1 Sarawak 2.36 8 8 3 5 14 2 1 11 0 2 5 1 Selangor & W.P 6.43 30 32 5 9 24 1 5 56 1 10 27 2 Kuala Lumpur

Population Ultrasound with Doppler No in million No % pmp Malaysia 26.64 387 100 15

Sector Public - 203 52 Private - 184 48

State Johor 3.17 31 8 10 Kedah & Perlis 2.11 31 8 15 Kelantan 1.53 21 5 14 Melaka 0.73 12 3 16 Negeri Sembilan 0.96 11 3 11 Pahang 1.45 13 4 9 Perak 2.28 25 6 11 Terengganu 1.04 6 2 6 Pulau Pinang 1.49 37 10 25 Sabah 3 31 8 10 Sarawak 2.36 29 7 12 Selangor & W.P Kuala Lumpur 6.43 140 36 22 *Note: 1. Counts for “Ultrasound with Doppler” units mentioned above exclude Echocardiocardiography units, which are mentioned under Chapter 11: Cardiology and Cardiothoracic Surgery Facilities and Devices.

CHAPTER 2 NUCLEAR MEDICINE FACILITIES AND DEVICES

EXPERT PANEL MEMBERS Chairperson: Dato’ Dr. Mohamed Ali Abdul Khader1

Members : Dr. Lee Boon Nang2, Dr. Ng Chen Siew 3, Dr. Felix Sundram4, Assoc. Prof Sazilah A. Sarji 5

1 Hospital Pulau Pinang, 2 Hospital Kuala Lumpur, 3 Hospital Sultanah Aminah, 4 Subang Jaya Medical Centre, 5 University Malaya Medical Centre

INTRODUCTION Since the early 1960’s, when nuclear medicine services first started in Malaysia, its scope has expanded from just providing diagnostic services to the present therapeutic and also interventional nuclear medicine. With the introduction of Positron Emission Tomography (PET), the setting up of cyclotron facility and the use of targeted delivery agents for imaging and therapy, the possibility of achieving earlier, more accurate and more specific diagnosis, it promises significant improvements in clinical outcomes. This increasing insight into the molecular origins of disease, the visualization of pathological changes at the cellular and biochemical level, before their anatomical changes occur shall without doubt reshape the whole pattern of healthcare.

Worldwide, the field of nuclear medicine has developed tremendously and has become an established medical specialty and has expanded to various fields of subspecialisations and also integration with other medical specialties to provide more comprehensive patient management.

Nuclear Medicine involves the use of radioactive isotopes (radioisotopes) to prevent, diagnose, and treat disease.

Scope of Nuclear Medicine Nuclear Medicine Service has 3 major sections: a) Clinical Nuclear Medicine b) Nuclear Pharmacy c) Nuclear Medicine Physics a) Clinical Nuclear Medicine The Clinical Nuclear Medicine section is the mainstay of the department providing the diagnostic and therapeutic aspect of nuclear medicine. This section incorporates the nuclear medicine physicians, medical officers, nurses and the technologists. b) Section of Nuclear Pharmacy The nuclear pharmacy section is managed by a pharmacist trained in nuclear medicine and handles the quality control, and the preparation of radiopharmaceuticals for nuclear medicine procedure. c) Nuclear Medicine Physics Section The Nuclear Medicine Physics section is managed by the nuclear medicine physicist who is also a key member of the nuclear medicine team. The responsibilities revolve around the safety issues in relation to patients, staff and the public, quality assurance relating to both the performance of key equipment as well as procedural factors contributing to the quality of service.

REPORT The nuclear medicine service in the Ministry of Health is to be setup as nuclear medicine department on a regional basis. These centres will play a bigger role as training centres and also develop a chosen subspecialty area to focus on at a tertiary level later on.

In Malaysia, the nuclear medicine services began its operation as a unit in the department of Radiotherapy in Kuala Lumpur Hospital and between in the next 30 years only 3 additional centres began its operation all within the Klang valley. It is only in the 1990’s that more centres were setup due to the advancement of nuclear medicine technologies both in the hardware and computerization. In the year 2007 there are a total of 12 nuclear medicine centers providing various degrees of services ranging from purely diagnostic to therapy and the more recent sophisticated Positron Emission Tomography.

However the provision of nuclear medicine services are provided by nuclear medicine setup under various jurisdictions like in the department of Radiology, Department of Internal Medicine, Department of Oncology and in one center under the department of Biomedical Imaging. Until 2005 there was no independent nuclear medicine department in the Ministry of Health.

To facilitate planned expansion, a National Nuclear Medicine Meeting was held on 2nd to 5th May 2002 in Johor Bahru, officiated by the Director General of Health, Malaysia. During this meeting, the major stakeholders involving nuclear medicine attended where various issues, problems, weaknesses were identified and extensively discussed. Recommendations and target for achievement were prioritized. All regional nuclear medicine centres would be equipped in phases with: • Hot lab providing dispensing of radioisotopes • Diagnostic nuclear medicine services • Therapeutic nuclear medicine services • Therapeutic nuclear medicine wards • Positron Emission Tomography (PET) services The nuclear medicine facilities and devices data collated are as below :

Table 1: Available Therapeutic and Diagnostic Facilities in Nuclear Medicine

Hospital with Radionuclide Population Nuclear Medicine Centre Isolation Ward

No in million No % pmp No % pmp Malaysia 26.64 5 100 0 12 100 0

Sector Public - 3 60 8 66 Private - 2 40 4 34

State Johor 3.17 0 0 0 1 8 0 Kedah & Perlis 2.11 0 0 0 0 0 0 Kelantan 1.53 1 20 1 1 8 1 Melaka 0.73 0 0 0 0 0 0 Negeri Sembilan 0.96 1 20 1 0 0 0 Pahang 1.45 0 0 0 0 0 0 Perak 2.28 0 0 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 Pulau Pinang 1.49 0 0 0 1 8 1 Sabah 3 0 0 0 0 0 0 Sarawak 2.36 0 0 0 1 8 0 Selangor & W.P. Kuala Lumpur 6.43 3 60 0 8 67 1 Table 2: Available Medical Devices in Nuclear Medicine

Total Gamma Single head 2-head Gamma 3-head Gamma Population Camera Units Gamma Camera Camera Camera No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 12 100 0 2 100 0 9 100 0 1 100 0

Sector Public - 10 83 2 100 7 78 1 100 Private - 2 17 0 0 2 22 0 0

State Johor 3.17 1 8 0 0 0 0 1 11 0 0 0 0 Kedah & Perlis 2.11 0 0 0 0 0 0 0 0 0 0 0 0 Kelantan 1.53 2 17 1 1 50 1 1 11 1 0 0 0 Melaka 0.73 0 0 0 0 0 0 0 0 0 0 0 0 N. Sembilan 0.96 0 0 0 0 0 0 0 0 0 0 0 0 Pahang 1.45 0 0 0 0 0 0 0 0 0 0 0 0 Perak 2.28 0 0 0 0 0 0 0 0 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 3 25 2 1 50 1 2 22 1 0 0 0 Sabah 3 0 0 0 0 0 0 0 0 0 0 0 0 Sarawak 2.36 2 17 1 0 0 0 2 22 1 0 0 0 Selangor & W.P 6.43 4 33 1 0 0 0 3 33 0 1 100 0 Kuala Lumpur

References : 1. Nuclear Medicine in the 21st Century: Contributing To Better Health Care, MOH DG Technical Report 2. 2006 Annual Report, Ministry of Health, Malaysia 3. Malaysian Statistics on Medicine, 2005

CHAPTER 3 Oncology FACILITIES AND DEVICES

Edited by: Ass. Prof. Dr. Fuad Ismail1

With contributions from: Dr. Ahmad Kamal Mohamed2, Dr. Mohd Roslan B. Haron3, Dr. Vincent Phua4, En. Mohd Farihan Jaffar4, Puan Rubiah Pakah4, Pn. Mahzom Pawanchek4

1 Pusat Perubatan Universiti Kebangsaan Malaysia, 2 Pusat Perubatan Subang Jaya, 3 Hospital Sultan Ismail, 4 Hospital Kuala Lumpur.

REPORT Radiotherapy is one of the cornerstones of cancer therapy, both for cure and palliation. Radiotherapy services are equipment based with 2 distinct modalities, teletherapy and brachytherapy.

Teletherapy is currently based on Linear Accelerators (LINAC) with older cobalt units available in a few hospitals. There are 5 cobalt units in the country. These are technically still working but are not used as they are being phased out to be replaced by linacs. The only working unit is in a private centre in Selangor.

Linacs form the backbone of radiotherapy with the capability to deliver 2-D & 3-D treatment as standard. There are a total of 30 linacs in Malaysia with a ratio of 1.17 per million population (pmp). This is far lower than the recommended ratio in UK of 4 PMP. Apart from the lack of equipment, there is also a great imbalance in the distribution of linacs in Malaysia with almost half concentrated in the Klang Valley (Selangor & Wilayah Persekutuan). Large states such as Kedah, Perak, Pahang and Terengganu still lack radiotherapy centres hence have no available equipment. As radiotherapy is given over several weeks, the lack of facilities results in patients having to move to another state for a protracted period of time for treatment. The other states have between 1-4 linacs each.

Improvements in technology have resulted in improved treatment delivery by improved radiation dosimetry. Five (5) radiotherapy centres are able to offer more sophisticated radiotherapy using Intensity Modulated Radiotherapy (IMRT). Other specialized equipment includes one (1) cyberknife device and linac based stereotactic devices (4), all in Klang Valley except one.

Brachytherapy is an important modality in radiotherapy especially in gynaecological malignancies. Both High Dose-Rate (HDR) and Low Dose-Rate (LDR) are equally effective. The overall capacity in the country is adequate for gynaecological treatment but due to unequal distribution, there is no services in some states namely Kedah, Pahang & Terengganu. Klang Valley has overcapacity with about half the available brachytherapy devices.

Radiotherapy may be given for palliation or for cure. Treatment time may be between 1 – 7 weeks. The current recommendation states that 50% of patient with cancer require radiotherapy treatment at some point. The incidence rate of cancer in Australia is over 4000 PMP compared to 1400 PMP in Malaysia. The required number of machines in Australia is estimated to be 6.5 per million population. Given that our incidence is about 3 times lower, the number of linacs required in our country should be about 60 machines in total. Equitable distribution of equipment is equally important.

Table 1: Available Therapeutic and Diagnostic Facilities in Oncology No Data to Date

Table 2: Available Medical Devices in Oncology

High dose Low dose Population Linear Accelerator IMRT Brachytherapy Brachytherapy No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 28 100 1 8 100 0 10 100 0 7 100 0

Sector Public - 14 50 6 75 5 50 3 43 Private - 14 50 2 25 5 50 4 57

State Johor 3.17 3 11 1 1 13 0 1 10 0 1 14 0 Kedah & 2.11 0 0 0 0 0 0 0 0 0 0 0 0 Perlis Kelantan 1.53 2 7 1 1 13 1 0 0 0 1 14 1 Melaka 0.73 2 7 3 0 0 0 2 20 3 0 0 0 Negeri 0.96 2 7 2 0 0 0 1 10 1 1 14 1 Sembilan Pahang 1.45 0 0 0 0 0 0 0 0 0 0 0 0 Perak 2.28 0 0 0 0 0 0 1 10 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 4 14 3 1 13 1 0 0 0 1 14 1 Sabah 3 1 4 0 0 0 0 1 10 0 0 0 0 Sarawak 2.36 3 11 1 1 13 0 0 0 0 1 14 0 Selangor & W.P Kuala 6.43 11 39 2 4 50 1 4 40 1 2 29 0 Lumpur

Co 60 Population CyberKnife * Equipment on phase out No in million No % pmp No % pmp Malaysia 26.64 1 100 0 1 100 0

Sector Public - 0 0 0 0 Private - 1 100 1 100

State Johor 3.17 0 0 0 0 0 0 Kedah & Perlis 2.11 0 0 0 0 0 0 Kelantan 1.53 0 0 0 0 0 0 Melaka 0.73 0 0 0 0 0 0 Negeri Sembilan 0.96 0 0 0 0 0 0 Pahang 1.45 0 0 0 0 0 0 Perak 2.28 0 0 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 Pulau Pinang 1.49 0 0 0 0 0 0 Sabah 3 0 0 0 0 0 0 Sarawak 2.36 0 0 0 0 0 0 Selangor & 6.43 1 100 0 1 100 0 W.P Kuala Lumpur

10 CHAPTER 4 ANAESTHESIOLOGY AND INTENSIVE CARE FACILITIES AND DEVICES

Edited by: Dato’ Dr. Jahizah Hassan1, Professor Marzida Mansor2, Associate Professor Choy Yin Choy3, Dr. Mary Suma Cardosa4, Dr. Irene Cheah5, Dr. Neoh Siew Hong6, Dato’ Dr. KH Teh 7.

1 Hospital Pulau Pinang, 2 Pusat Perubatan Universiti Malaya, 3 Pusat Perubatan Universiti Kebangsaan Malaysia, 4 Hospital Selayang, 5 Hospital Kuala Lumpur, 6 Hospital Ipoh, 7 Hospital Sultanah Bahiyah.

INTRODUCTION The data on medical devices for Anaesthesiology and Intensive Care was collected over duration of one-year using survey forms that were sent to both public and private hospitals in Malaysia. The availability of the therapeutic and diagnostic facilities in anaesthesia was based on the number of Intensive Care Units (ICU), High Dependency Units, Anaesthetic Clinics and Acute Pain Services in Malaysia.

Table 1: Available Therapeutic and Diagnostic Facilities in Anaesthesiology

Paediatric Adults Burns Paediatric Burns Adult Intensive Population Intensive Care Intensive Care Intensive Care Care Unit (ICU) Unit (PICU) Unit Unit

No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 103 100 4 32 100 1 12 100 0 3 100 0

Sector Public - 65 55 12 38 10 83 2 67 Private - 38 45 20 62 2 17 1 33

State Johor 3.17 13 13 4 3 10 1 0 0 0 0 0 0

Kedah & Perlis 2.11 9 9 4 1 3 0 2 17 1 1 33 0

Kelantan 1.53 4 4 3 3 9 2 1 8 1 0 0 0 Melaka 0.73 5 5 7 1 3 1 1 8 1 0 0 0 N. Sembilan 0.96 5 5 5 1 3 1 0 0 0 0 0 0 Pahang 1.45 4 4 3 1 3 1 1 8 1 0 0 0 Perak 2.28 10 10 4 3 9 1 0 0 0 0 0 0 Terengganu 1.04 2 2 2 1 3 0 0 0 0 0 0 0 Pulau Pinang 1.49 13 13 9 4 12 3 0 0 0 1 33 1 Sabah 3 5 5 2 3 9 1 0 0 0 0 0 0 Sarawak 2.36 7 7 3 2 6 1 1 8 0 0 0 0 Selangor & W.P 6.43 26 25 4 9 28 1 6 50 1 1 33 0 Kuala Lumpur

11 Population High Dependency Unit Anaesthetic Clinic Acute Pain Service

No in million No % pmp No % pmp No % pmp Malaysia 26.64 55 100 2 30 100 1 38 100 1

Sector Public - 21 38 15 50 38 100 Private - 34 62 15 50 0 0

State Johor 3.17 8 15 3 4 13 1 5 13 2 Kedah & Perlis 2.11 4 7 2 2 7 1 4 11 2 Kelantan 1.53 2 4 1 1 3 1 2 5 1 Melaka 0.73 3 5 4 2 7 3 2 5 3 Negeri Sembilan 0.96 3 5 3 1 3 1 2 5 2 Pahang 1.45 3 5 2 2 7 1 2 5 1 Perak 2.28 5 9 2 2 7 1 3 8 1 Terengganu 1.04 2 4 2 0 0 0 1 3 1 Pulau Pinang 1.49 4 7 3 5 17 3 2 5 1 Sabah 3 2 4 1 3 10 1 1 3 0 Sarawak 2.36 6 11 3 3 10 1 4 11 2 Selangor & W.P. 6.43 13 24 2 5 17 1 10 26 2 Kuala Lumpur

The data showed that Malaysia has 4 adult, 1 paediatric and 0 adult and paediatric burns ICU per million population (pmp) as shown in Table 1. The distribution of the adult intensive care is almost equal between the private and public hospitals; however there are more paediatric intensive care units available in the private sector. In the case of adult and paediatric ICUs, majorities are in the public sectors. With regards to distribution of ICU throughout Malaysia it is not surprising to find that majority of the intensive care services are located in places where there are major public or private hospitals. The availability of adult ICU for instance varies from 26% in Selangor and W.P Kuala Lumpur to 2% in Terengganu. This is probably due to maldistribution of human resources and availability of private hospitals, which is probably influenced by population’s income, geographical demarcation and urbanization. The paediatric ICU availability follows the similar trend as the adult ICU and in fact, their services are even more deficient as compared to adult ICU. We have 1 paediatric ICU pmp. Their availability ranges from as low as 0% in Terengganu to 20% in Selangor& WP Kuala Lumpur. Adult and paediatric burns ICU are the most deficient of all the intensive care facilities. More of these services should be made available in the near future.

High dependency unit is available in most of the states as a step down unit. It is encouraging to note that the anaesthetic clinic services have taken off in Malaysia, both in the public and private sectors. This reflects that a proportion of patients schedule for elective surgery were seen prior to surgery for optimization. This anaesthetic clinic services will certainly reduce cancellation rate of elective surgery and improves patient care and safety. In terms of medical devices, there are not many devices are needed in the anaesthetic clinic. Perhaps in future when more anaesthetists are trained to do specific echocardiography to assess the cardiovascular status of patients preoperatively, then, this statistic on anaesthetic clinic may be more relevant.

The data showed that Acute Pain Services are well establish in most major public hospitals but not available in private hospitals. We are fully aware that such services are available in majority of the private hospitals using similar devices. The data is not being captured probably due to the fact that acute pain services are being provided by individual practitioner / anaesthetist rather than by the acute pain team.

12 Table 2: Available Medical Devices in Anaesthesiology High Frequency Anaesthesia Adult Portable Intensive Care Population Adult Intensive Ventilator Ventilator Ventilator Care Ventilator No in No % pmp No % pmp No % pmp No % pmp million Malaysia 26.64 655 100 25 236 100 9 793 100 30 26 100 1

Sector Public - 451 69 184 78 555 70 21 81 Private - 204 31 w 52 22 238 30 5 19

State Johor 3.17 66 10 21 22 9 7 84 11 26 1 4 0 Kedah & 2.11 30 5 14 13 6 6 31 4 15 0 0 0 Perlis Kelantan 1.53 19 3 12 15 6 10 50 6 33 0 0 0 Melaka 0.73 21 3 29 12 5 16 41 5 56 0 0 0 N. Sembilan 0.96 11 2 11 4 2 4 14 2 15 0 0 0 Pahang 1.45 18 3 12 10 4 7 32 4 22 1 4 1 Perak 2.28 49 7 21 18 8 8 46 6 20 0 0 0 Terengganu 1.04 21 3 20 4 2 4 25 3 24 0 0 0 P. Pinang 1.49 79 12 53 31 13 21 134 17 90 0 0 0 Sabah 3 48 7 16 21 9 7 29 4 10 1 4 0 Sarawak 2.36 65 10 28 18 8 8 64 8 27 0 0 0 Selangor & W.P 6.43 228 35 35 68 29 11 243 31 38 23 88 4 Kuala Lumpur

Paediatric High Neonatal / Patient Frequency Flexible Fiber Paediatric Controlled Population Oscillatory Optic Intubation Intensive Care Analgesia (PCA) Ventilator Scope Ventilator Infusion Pump (HFOV) No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 379 100 14 41 100 2 121 100 5 387 100 15

Sector Public - 303 80 38 93 86 71 279 72 Private - 76 20 3 7 35 29 108 28

State Johor 3.17 36 9 11 5 12 2 8 7 3 15 4 4 Kedah & Perlis 2.11 32 8 15 7 17 3 6 5 3 15 4 7 Kelantan 1.53 20 5 13 6 15 4 7 6 5 16 4 10 Melaka 0.73 9 2 12 1 2 1 2 2 3 11 3 15 N. Sembilan 0.96 20 5 21 1 2 1 7 6 7 6 2 6 Pahang 1.45 18 5 12 1 2 1 4 3 3 24 6 17 Perak 2.28 27 7 12 2 5 1 8 7 4 36 9 16 Terengganu 1.04 15 4 14 1 2 1 5 4 5 7 2 7 P. Pinang 1.49 35 9 23 2 5 1 10 8 7 43 11 29 Sabah 3 44 12 15 6 15 2 7 6 2 12 3 4 Sarawak 2.36 18 5 8 2 5 1 8 7 3 30 8 13 Selangor & W.P 6.43 105 28 16 7 17 1 49 40 8 173 45 27 Kuala Lumpur

13 Population Level 1 Infusion Pump With or Without Hotline

No in million No % pmp Malaysia 26.64 491 100 18

Sector Public - 293 60 Private - 198 40

State Johor 3.17 46 9 15 Kedah & Perlis 2.11 42 9 20 Kelantan 1.53 29 6 19 Melaka 0.73 12 2 16 Negeri Sembilan 0.96 22 5 23 Pahang 1.45 19 4 13 Perak 2.28 77 16 34 Terengganu 1.04 35 7 34 Pulau Pinang 1.49 41 8 27 Sabah 3 23 5 8 Sarawak 2.36 7 1 3 Selangor & W.P Kuala Lumpur 6.43 138 28 21

The data in Table 2 concentrate on ventilators, which comprise of anaesthesia ventilator, adult portable ventilator, ICU ventilator, high frequency adult ICU ventilator and paediatric and neonatal high frequency oscillatory. These equipment are the common items available in the facilities in Table 1 but the figures may not be a true reflection of the services rendered to the population as some of these equipment may not being used due to shortage of anaesthetists and nurses. Similarly, the same reasoning applies to the data on anaesthesia ventilators (anaesthetic machines) and flexible fibre optic intubation scopes. In future, it may be more useful to have a statistics on the number of operation theatres in each hospitals surveyed as these two devices are mostly available in the operating theatre (OT) rather than in the intensive care. With regards to the anaesthesia ventilators, we are assuming that these ventilators are the ones that are attached to the anaesthetic machines.

The main data collection on the device used for acute pain service is patient controlled analgesia (PCA) infusion pump. The pumps are widely available in both private and public hospitals in a reasonable numbers, indicating that the services are being provided in both sectors. The last equipment in Table 2 is level 1 infusion pump with or without hotline. The figures combined the generic and specific for rapid infusion. The hotline is widely available in most hospital. However Level 1infusion pumps are not widely available.

This is our first effort in trying to compile our own data on medical devices for our fraternity; therefore the data may not reflect the actual numbers, as many of the private hospitals are not included. The range of equipment covered is also inadequate and more detailed definitions and information should be made available in the future.

14 CHAPTER 5 GENERAL SURGERY FACILITIES AND DEVICES EXPERT PANEL MEMBERS Chairperson : Dato’ Dr. Dato’ Dr. Zakaria Bin Zahari 1

Members : Dr. Mohammed Saffari Mohammed Haspani1, Dr. Mohd Mazri Yahya1

1 Hospital Kuala Lumpur

Table 1: Available Therapeutic and Diagnostic Facilities in General Surgery

Day Case Surgery Surgical Neonatal Anorectal High Dependency Population Unit Intensive Care Physiology (Surgical) Unit Unit (SNICU) Laboratory

No in No % pmp No % pmp No % pmp No % pmp million Malaysia 26.64 63 100 2 41 100 2 9 100 0 1 100 0

Sector Public - 27 43 17 41 7 78 1 100 Private - 36 57 24 59 2 22 0 0

State Johor 3.17 4 6 1 2 5 1 1 11 0 0 0 0 Kedah & 2.11 6 10 3 5 12 2 1 11 0 0 0 0 Perlis Kelantan 1.53 3 5 2 3 7 2 1 11 1 0 0 0 Melaka 0.73 2 3 3 3 7 4 1 11 1 0 0 0 N. Sembilan 0.96 1 2 1 2 5 2 1 11 1 0 0 0 Pahang 1.45 4 6 3 3 7 2 0 0 0 0 0 0 Perak 2.28 7 11 3 4 10 2 0 0 0 0 0 0 Terengganu 1.04 0 0 0 1 3 1 0 0 0 0 0 0 P. Pinang 1.49 5 8 3 5 12 3 1 11 1 0 0 0 Sabah 3 5 8 2 2 5 1 1 11 0 0 0 0 Sarawak 2.36 7 11 3 3 7 1 0 0 0 0 0 0

Selangor & W.P. 6.43 19 30 3 8 20 1 2 22 0 1 100 0 Kuala Lumpur

15 Population Liver Transplant Unit Robotic Surgical Suite No in million No % pmp No % pmp Malaysia 26.64 1 100 0 0 0 0

Sector Public - 1 100 0 0 Private - 0 0 0 0

Table 2: Available Medical Devices in General Surgery

Gamma Probe Automated Vacuum Assisted For Sentinel Node Population Breast Tissue Breast Biopsy ABBI System And Parathyroid Core Biopsy Gun Gun Surgery No in No % pmp No % pmp No % pmp No % pmp million Malaysia 26.64 31 100 1 4 100 0 0 0 0 1 100 0

Sector Public - 24 80 2 50 0 0 0 0 Private - 7 23 2 50 0 0 1 100

State Johor 3.17 1 3 0 0 0 0 0 0 0 0 0 0 Kedah & Perlis 2.11 3 10 1 1 25 0 0 0 0 0 0 0 Kelantan 1.53 4 13 3 0 0 0 0 0 0 0 0 0 Melaka 0.73 2 6 3 0 0 0 0 0 0 0 0 0 N. Sembilan 0.96 0 0 0 0 0 0 0 0 0 0 0 0 Pahang 1.45 2 6 1 1 25 1 0 0 0 0 0 0 Perak 2.28 3 10 1 0 0 0 0 0 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 3 10 2 1 25 1 0 0 0 1 100 1 Sabah 3 1 3 0 0 0 0 0 0 0 0 0 0 Sarawak 2.36 2 6 1 0 0 0 0 0 0 0 0 0 Selangor & W.P. 6.43 10 33 2 1 25 0 0 0 0 0 0 0 Kuala Lumpur

16 Operating Table Ultrasonic With Yellow-Fin Argon Plasma Harmonic Dissector and Population Boots And Jacknife Coagulation Scalpel Aspirator Positioning System (CUSA) Capability No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 123 100 5 45 100 2 40 100 2 33 100 1

Sector Public - 51 41 23 51 24 60 11 33 Private - 72 59 22 49 16 40 22 67

State Johor 3.17 18 15 6 2 4 1 2 5 1 2 6 1 Kedah & Perlis 2.11 5 4 2 5 11 2 5 12 2 0 0 0 Kelantan 1.53 4 3 3 3 7 2 3 8 2 0 0 0 Melaka 0.73 6 5 8 1 2 1 0 0 0 6 18 8 Negeri Sembilan 0.96 7 6 7 1 2 1 0 0 0 0 0 0 Pahang 1.45 3 2 2 2 4 1 6 15 4 4 12 3 Perak 2.28 18 15 8 5 11 2 3 8 1 3 9 1 Terengganu 1.04 1 1 1 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 20 16 13 10 22 7 5 12 3 3 9 2 Sabah 3 12 10 4 1 2 0 1 3 0 1 3 0 Sarawak 2.36 11 9 5 3 7 1 2 5 1 4 12 2 Selangor & W.P. 6.43 18 15 3 12 27 2 13 32 2 10 31 2 Kuala Lumpur

Haemorrhoid Transrectal Anorectal Pudendal Nerve Artery Ligation Population Ultrasound Manometer Latency Test (HAL) Doppler Equipment Equipment No in No % pmp No % pmp No % pmp No % pmp million Malaysia 26.64 4 100 0 0 0 0 1 100 0 3 100 0

Sector Public - 2 50 0 0 0 0 2 67 Private - 2 50 0 0 1 100 1 33

State Johor 3.17 0 0 0 0 0 0 0 0 0 0 0 0 Kedah & Perlis 2.11 1 25 0 0 0 0 0 0 0 1 33 0 Kelantan 1.53 1 25 1 0 0 0 0 0 0 0 0 0 Melaka 0.73 0 0 0 0 0 0 0 0 0 0 0 0 N. Sembilan 0.96 0 0 0 0 0 0 0 0 0 0 0 0 Pahang 1.45 0 0 0 0 0 0 0 0 0 0 0 0 Perak 2.28 0 0 0 0 0 0 0 0 0 1 33 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 1 25 1 0 0 0 0 0 0 0 0 0 Sabah 3 0 0 0 0 0 0 0 0 0 0 0 0 Sarawak 2.36 1 25 0 0 0 0 1 100 0 0 0 0 Selangor & W.P. 6.43 0 0 0 0 0 0 0 0 0 1 33 0 Kuala Lumpur

17 Radiofrequency Liver Dialysis Endovenous Laser Population Craniotome Ablation Unit Unit (MARS) Unit No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 3 100 0 0 0 0 4 100 0 74 100 3

Sector Public - 0 0 0 0 0 0 50 68 Private - 3 100 0 0 4 100 24 32

State Johor 3.17 0 0 0 0 0 0 0 0 0 10 14 3 Kedah & Perlis 2.11 0 0 0 0 0 0 0 0 0 6 8 3 Kelantan 1.53 0 0 0 0 0 0 0 0 0 1 1 1 Melaka 0.73 0 0 0 0 0 0 0 0 0 3 4 4 N. Sembilan 0.96 0 0 0 0 0 0 0 0 0 2 3 2 Pahang 1.45 0 0 0 0 0 0 0 0 0 4 5 3 Perak 2.28 0 0 0 0 0 0 0 0 0 7 10 3 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 3 100 2 0 0 0 1 25 1 6 8 4 Sabah 3 0 0 0 0 0 0 0 0 0 4 5 1 Sarawak 2.36 0 0 0 0 0 0 0 0 0 12 16 5 Selangor & W.P. 6.43 0 0 0 0 0 0 3 75 0 19 26 3 Kuala Lumpur

Paediatric Paediatric Thoracoscopy Paediatric Upper Cystoscopy Set Lower And Abdominal Gastrointestinal For Urology Gastrointestinal Laparoscopy Set Population Diagnostic And And Complex Diagnostic And For Minimally Therapeutic Intersex Surgery Therapeutic Invasive Endoscope Set Endoscope Set Laparoscopic Surgery No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 14 100 1 12 100 0 15 100 1 13 100 0

Sector Public - 10 71 8 67 8 53 3 21 Private - 4 29 4 33 7 47 10 86

State Johor 3.17 2 14 1 2 17 1 1 7 0 0 0 0 Kedah & Perlis 2.11 2 14 1 1 8 0 1 7 0 1 7 0 Kelantan 1.53 2 14 1 2 17 1 2 13 1 0 0 0 Melaka 0.73 1 7 1 1 8 1 1 7 1 1 7 1 N. Sembilan 0.96 1 7 1 1 8 1 2 13 2 0 0 0 Pahang 1.45 0 0 0 0 0 0 0 0 0 0 0 0 Perak 2.28 0 0 0 0 0 0 2 13 1 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 1 7 1 1 8 1 2 13 1 10 78 7 Sabah 3 0 0 0 0 0 0 0 0 0 0 0 0 Sarawak 2.36 0 0 0 0 0 0 1 7 0 0 0 0 Selangor & W.P. 6.43 5 36 1 4 34 1 3 20 0 1 7 0 Kuala Lumpur

18 Vacuum Assisted Robotic Surgery Population Closure System Dermatome System (VACS) No in million No % pmp No % pmp No % pmp Malaysia 26.64 22 100 1 51 100 2 2 100 0

Sector Public - 11 50 34 67 2 100 Private - 11 50 17 33 0 0

State Johor 3.17 1 5 0 3 6 1 0 0 0 Kedah & Perlis 2.11 0 0 0 8 15 4 0 0 0 Kelantan 1.53 4 18 3 4 8 3 0 0 0 Melaka 0.73 1 5 1 1 2 1 0 0 0 Negeri Sembilan 0.96 0 0 0 1 2 1 0 0 0 Pahang 1.45 0 0 0 2 4 1 0 0 0 Perak 2.28 1 5 0 5 10 2 0 0 0 Terengganu 1.04 0 0 0 2 4 2 0 0 0 Pulau Pinang 1.49 1 5 1 6 12 4 0 0 0 Sabah 3 1 5 0 2 4 1 0 0 0 Sarawak 2.36 10 45 4 4 8 2 1 50 0 Selangor & W.P. 6.43 3 14 0 13 25 2 1 50 0 Kuala Lumpur

CHAPTER 6 ORTHOPAEDIC AND TRAUMATOLOGY FACILITIES AND DEVICES

Edited by: Dr. Kamariah Nor MD1., Dr. Mohammad Anuar H.A2., Dr. Ng YO3, Dato’ Dr. Ramanathan R4, Dr. Lee JK 5 and Dr. Mahathar AW.1.

1 Hospital Kuala Lumpur, 2 Hospital Raja Perempuan Zainab II, 3 Hospital Ampang, 4 Hospital Ipoh, 5 Pusat Perubatan Pantai Bangsar.

REPORT External fixation is the commonest mode of treatment for open fractures. Generally all hospitals with orthopedic services will have at least one external fixator set. So, generally in Malaysia there are 333 sets of external fixators, which equate roughly to 13 sets per million population. However, in Sabah, there are only 15 sets of external fixators that are generally inadequate for the 3 million population. The distribution of external fixators is balanced between the public and private sector. However in the public sector, the distributions were high in urban areas and Wilayah Persekutuan.

Overall, there is some mal-distribution of external fixators, with higher concentration in Penang (22 PMP) but low concentration in Sabah. As for Ilizarov set, there are higher numbers in Sarawak (5PMP) as compared to other states (1-2 PMP). The panel recommends that each hospital which provides orthopaedic and trauma services should have at least one set of external fixators (each for upper limb, lower limb and mini set).

Currently there are only 116 sets of upper limb external fixators (4 set PMP), which is not enough to deal with the increasing number of upper limb injuries.

The Panel also suggests a more proper definition and clarification of external fixator sets. The specification can be varies from different companies with different capacities. In addition, data on trained personnel available to operate the devices in that particular hospital may be useful. This will indicate whether the devices are being used optimally or if they can be mobilized to other hospitals if trained personnel are not available or have been transferred.

Table 1: Available Therapeutic and Diagnostic Facilities in Orthopedic & Traumatology No Data To Date

21 Table 2: Available Medical Devices in Orthopedics & Traumatology

Total External External Fixator External Fixator External Fixator Population Fixator Unit Lower Limb Unit Upper Limb Unit Mini Unit

No in No % pmp No % pmp No % pmp No % pmp million Malaysia 26.64 333 100 13 151 100 6 116 100 4 67 100 3

Sector Public - 213 64 98 65 73 63 44 66 Private - 120 36 53 35 43 37 23 34

State Johor 3.17 26 8 8 10 7 3 8 7 3 8 12 3 Kedah & 2.11 35 11 17 16 10 8 12 10 6 7 10 3 Perlis Kelantan 1.53 20 6 13 10 7 7 6 5 4 4 6 3 Melaka 0.73 8 2 11 3 2 4 3 3 4 2 3 3 N. Sembilan 0.96 10 3 10 4 3 4 5 4 5 1 1 1 Pahang 1.45 15 4 10 6 4 4 5 4 3 4 6 3 Perak 2.28 34 10 15 15 10 7 12 10 5 7 10 3 Terengganu 1.04 8 2 8 3 2 3 3 3 3 2 3 2 P. Pinang 1.49 33 10 22 18 12 12 11 10 7 4 6 3 Sabah 3 15 4 5 6 4 2 5 4 2 4 6 1 Sarawak 2.36 33 10 14 15 10 6 10 9 4 8 12 3 Selangor & W.P 6.43 96 30 15 45 29 7 36 31 6 16 24 2 Kuala Lumpur

Population Illizarov Unit

No in million No % pmp Malaysia 26.64 47 100 2

Sector Public - 34 72 Private - 13 28

State Johor 3.17 4 9 1 Kedah & Perlis 2.11 2 4 1 Kelantan 1.53 2 4 1 Melaka 0.73 2 4 3 Negeri Sembilan 0.96 1 2 1 Pahang 1.45 1 2 1 Perak 2.28 4 9 2 Terengganu 1.04 2 4 1 Pulau Pinang 1.49 2 4 1 Sabah 3 3 6 1 Sarawak 2.36 11 23 5 Selangor & W.P Kuala Lumpur 6.43 13 28 2

22 CHAPTER 7 pHYSIOTHERAPY And occupational therapy FACILITIES AND DEVICES

Contributors: Datin Hjh Asiah Bt Hashim1, Cik Katijjah Be Mohd Ali2, Pn. Misnah Roslam3, Pn. Tan Wai Choo4, Pn. Wong Swee Fong5, Pn. Lim Khee Li1, Pn. Hjh. Hamidah Hj. Ariffin6, Pn. Khuzaimah Abd. Aziz1, Pn. Jamaliah Musa1, Pn. Zalila Kashim1

1 Hospital Kuala Lumpur, 2 Pusat Perubatan Universiti Kebangsaan Malaysia, 3 Hospital Serdang, 4 Hospital Sungai Buloh, 5 Hospital Tengku Ampuan Rahimah, 6 Hospital Selayang

REPORT The data portrayed in this report are data from the NMDS (2007) as well as data collated by the expert panel of this discipline (2008 data). Whilst the data collected in 2007 includes input from the private sector institutions, those of 2008 below are all from the public hospitals and health clinics in Malaysia. Figures from the private sectors, University Hospitals and Arm Forces Hospitals in 2008 were not obtained.

The findings are as follows:- There is an increase of number of device per million population (PMP) from year 2007 to 2008. MEDICAL DEVICE PMP Transcutaneous Electrical Nerve Stimulation (TENS) From 13 to 14 Short wave Diathermy (SWD) From 6-9 Pressure Feedback* From 2-3 *Note : The pressure feedback survey done in 2008 refers to a simple device that is commonly used to measure the core muscle work of cervical and lumbar region.

There is decrease of number of device per million population (PMP) from year 2007 to 2008 : MEDICAL DEVICE PMP Ultrasound* From 11-7 Laser From 3-2 Continuous Passive Motion Exerciser From 2-0 *Note: There is a doubt whether the Neuromuscular Ultrasound Therapy stimulation system is referred to just an ultrasound machine which is commonly used in the physiotherapy department and Klinik Kesihatan in Malaysia.

The number of devices shown is not proportionate to the population of the respective states. It is most likely based on the demand of the cases seen and the services provided by the hospitals. The Klang valley is the most populated but does not have the most number of devices such as SWD, TENS, Ultrasound, laser, pressure feedback and CPM.

Conclusion: The figures obtained for devices compared with the population (PMP) are very far from desirable stage. Even though with addition of devices from the private sectors, it still makes no difference in number of devices in per million population as demonstrated in 2007.

23 Table 1: Available Therapeutic and Diagnostic Facilities in Physiotherapy and Occupational Therapy No Data To Date

Table 2: Available Medical Devices in Physiotherapy and Occupational Therapy

Transcutaneous Electrical Nerve Short wave Diathermy Population Stimulation (TENS) (SWD)

No in million No % pmp No % pmp Year ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 Malaysia 26.64 333 - 100 - 13 - 163 - 100 - 6 -

Sector - Public - 268 374 80 - 123 173 75 - Private 65 ND 20 - 40 ND 25 -

State Johor 3.17 31 22 9 6 10 7 8 13 5 7 3 4 Kedah & Perlis 2.11 11 39 3 10 5 18 7 15 4 8 3 7 Kelantan 1.53 11 17 3 5 7 11 10 9 6 5 7 6 Melaka 0.73 17 8 5 2 23 11 6 3 4 2 8 4 N. Sembilan 0.96 8 16 2 5 8 17 6 9 4 5 6 9 Pahang 1.45 16 39 5 10 11 27 12 17 7 10 8 12 Perak 2.28 17 35 5 9 7 15 14 16 9 10 6 7 Terengganu 1.04 12 12 4 3 12 12 11 16 7 10 11 15 Pulau Pinang 1.49 35 20 11 5 23 13 14 9 9 5 9 6 Sarawak 2.36 31 34 9 9 13 14 18 17 11 10 8 7 Sabah 3 18 28 6 8 6 9 9 19 6 11 3 6 Selangor & W.P 6.43 126 104 38 28 20 16 48 30 29 17 7 5 Kuala Lumpur

24 Continuous Passive Motion Population Ultrasound Therapy Exerciser (CPM) No in million No % pmp No % pmp Year ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 Malaysia 26.64 287 - 100 - 11 - 48 - 100 - 2 -

Sector - Public - 223 192 78 - 29 11 60 - Private 64 ND 22 - 19 ND 40 -

State Johor 3.17 14 15 5 8 4 5 3 1 6 9 1 0 Kedah & Perlis 2.11 10 18 3 9 5 9 0 3 0 27 0 1 Kelantan 1.53 7 10 2 5 5 7 0 0 0 0 0 0 Melaka 0.73 12 5 4 3 16 7 0 0 0 0 0 0 Negeri Sembilan 0.96 5 7 2 4 5 7 1 0 2 0 1 0 Pahang 1.45 12 17 4 9 8 12 2 0 4 0 1 0 Perak 2.28 10 21 3 11 4 9 9 0 19 0 4 0 Terengganu 1.04 4 13 1 7 4 13 0 0 0 0 0 0 Pulau Pinang 1.49 22 11 8 6 15 7 6 4 13 2 4 3 Sarawak 2.36 17 22 8 11 7 9 2 1 4 9 1 0 Sabah 3 16 24 8 123 5 8 2 1 4 9 1 0 Selangor & W.P 6.43 158 29 56 15 25 5 23 1 48 9 3 0 Kuala Lumpur

Population Laser Therapy Pressure Biofeedback System

No in million No % pmp No % pmp

Year ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 ‘07 ‘08 Malaysia 26.64 74 - 100 - 3 - 44 - 100 - 2 -

Sector - Public - 56 58 76 - 41 84 93 - Private 18 ND 24 - 3 ND 7 -

State Johor 3.17 3 2 4 3 1 1 6 1 14 1 2 0 Kedah & Perlis 2.11 2 3 3 5 1 1 1 14 2 17 0 7 Kelantan 1.53 3 4 4 7 2 5 2 7 5 8 1 5 Melaka 0.73 2 0 3 3 1 7 2 8 1 10 Negeri Sembilan 0.96 3 3 4 5 3 3 2 4 5 5 2 4 Pahang 1.45 6 7 8 12 4 5 2 8 5 10 1 6 Perak 2.28 13 8 18 14 6 4 5 15 11 17 2 7 Terengganu 1.04 1 2 1 3 1 2 1 4 2 5 1 4 Pulau Pinang 1.49 8 3 11 5 5 2 2 5 5 6 1 3 Sarawak 2.36 3 3 4 5 1 2 7 8 15 10 3 3 Sabah 3 3 7 4 12 1 2 6 4 14 5 2 1 Selangor & W.P 6.43 27 16 36 29 4 2 9 7 20 8 1 1 Kuala Lumpur

CHAPTER 8 Obstetrics & Gynaecology FACILITIES AND DEVICES Edited by : Dr. Murali Ganesalingam1

With contributions from : Dr. Krishnakumar a/l Harikrishnan2, Dr. R.P Japaraj3, Dr. Zaridah Shaffie4

1 Hospital Kuala Lumpur, 2 Hospital Tuanku Ja’afar, 3 Hospital Ipoh, 4 Hospital Tuanku Fauziah

INTRODUCTION There are various types of equipment being used within the obstetrics and gynaecology discipline. What would improve our ability to determine the best equipment to purchase would be a pre-survey questionnaire on the equipment and their make and the benefits and disadvantages of a particular brand that is currently in use.

Equipment such as suction pumps are equipment that are currently part of any operating theatre set up and there is no need to purchase such equipment specifically for suction curettage as we used to previously when suction pumps were not part of standard operating theatre equipment. Such items must be identified and deleted from future surveys.

Hospitals are currently built as turnkey projects and come fully equipped. There must be a system to capture the equipment that is in place and a system to ensure that future projects need to secure appropriate approvals before furnishing equipment to hospitals.

We are now using more disposable equipment. Vacuum extractors for delivering babies for example are now available in disposable form. A study should be done on these to assess the quality of the products and their effectiveness in clinical use.

Postal studies do not work, as the response rate and response time are not under the control of the agency carrying out the study. Small groups of investigators should be formed to represent the various disciplines and perhaps work out a method whereby these groups can visit hospitals in a staggered manner and obtain information first hand.

Other equipment that needs to be assessed from obstetrics and gynaecology would be: 1. Equipment for urodynamic studies 2. Equipment used in assisted reproduction 3. Laparoscopic equipment 4. Hysteroscopic equipment 5. Colposcopic equipment 6. The various stirrups used during gynaecological surgery 7. Gynaecological examination couches for office examination

27 Table 1: Available Therapeutic and Diagnostic Facilities in Obstetrics & Gynaecology

Labour Suite Gynaecology Assisted Reproductive Population Oncology Unit Centre (Fertility Center) No in million No % pmp No % pmp No % pmp Malaysia 26.64 198 100 5 10 100 0 16 100 1

Sector Public - NC - 5 50 NC - Private - NC - 5 50 NC -

State Johor 3.17 32 16 10 1 10 0 3 19 1 Kedah & Perlis 2.11 23 12 11 0 0 0 0 0 0 Kelantan 1.53 12 6 8 0 0 0 0 0 0 Melaka 0.73 8 4 11 3 30 4 1 6 1 Negeri 0.96 15 8 15 1 10 1 0 0 0 Sembilan Pahang 1.45 8 4 6 0 0 0 0 0 0 Perak 2.28 12 6 5 0 0 0 1 6 0 Terengganu 1.04 6 3 6 0 0 0 0 0 0 Pulau Pinang 1.49 15 8 10 1 10 1 3 19 2 Sabah 3 20 10 7 1 10 0 2 12 0 Sarawak 2.36 20 10 8 0 0 0 1 6 0 Selangor & W.P 6.43 27 14 4 3 30 0 5 31 1 Kuala Lumpur

Table 2: Available Medical Devices in Obstetrics & Gynaecology Total Cardiotocograph External Internal Combined (assume each CTG Population Cardiotocograph Cardiotocograph Internal and has internal and External CTG external CTG functions) No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 789 100 30 581 100 22 196 100 7 76 - -

Sector Public - NC - 419 72 166 85 NC - Private - NC - 163 28 30 15 NC -

State Johor 3.17 100 13 31 38 7 12 7 4 2 ND - - Kedah & Perlis 2.11 44 5 21 43 7 20 16 8 8 6 - 3 Kelantan 1.53 38 5 25 29 5 19 21 11 14 5 - 3 Melaka 0.73 40 5 55 13 2 18 3 2 4 15 - 21 N. Sembilan 0.96 40 5 42 31 5 32 6 3 6 5 - 5 Pahang 1.45 25 3 17 20 3 14 8 4 6 7 - 5 Perak 2.28 54 7 24 45 8 20 19 10 8 32 - 14 Terengganu 1.04 23 3 22 23 4 22 4 2 4 2 - 2 P. Pinang 1.49 55 7 37 48 8 32 14 7 9 4 - 3 Sabah 3 69 9 23 58 10 19 25 13 8 ND - - Sarawak 2.36 107 14 45 47 8 20 14 7 6 ND - - Selangor & W.P 6.43 194 25 30 187 33 29 59 29 9 ND - - Kuala Lumpur

28 Hysteroscope Transabdominal Transvaginal Colposcope Population system Transducer Transducer system Ultrasound Ultrasound No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 91 100 3 87 100 3 279 100 10 195 100 8

Sector Public - NC - NC - NC - NC - Private - NC - NC - NC - NC -

State Johor 3.17 18 20 5 17 20 5 60 21 19 55 27 17 Kedah & Perlis 2.11 7 8 3 2 2 1 21 8 10 14 7 7 Kelantan 1.53 4 4 3 4 5 3 10 4 7 8 4 5 Melaka 0.73 4 4 5 3 3 4 20 7 27 15 7 21 N. Sembilan 0.96 6 7 6 5 6 5 25 9 26 15 7 16 Pahang 1.45 2 2 1 3 3 2 6 2 4 3 1 2 Perak 2.28 4 4 2 12 14 5 15 5 7 12 6 5 Terengganu 1.04 1 1 1 3 3 3 3 1 3 3 1 3 P. Pinang 1.49 8 9 5 5 6 3 14 5 9 13 6 9 Sabah 3 8 9 3 3 3 1 22 8 7 12 6 4 Sarawak 2.36 7 8 3 6 7 3 14 5 6 6 3 3 Selangor & W.P 6.43 22 24 3 24 28 4 69 25 11 47 23 7 Kuala Lumpur

Blood gas Suction and Amnioscope Laparoscope Population machine for fetal Curettage System system system sampling No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 314 100 12 160 100 6 107 100 4 78 100 3

Sector Public - NC - NC - NC - NC - Private - NC - NC - NC - NC -

State Johor 3.17 37 12 12 20 13 6 15 14 5 18 23 6 Kedah & Perlis 2.11 17 5 8 0 0 0 0 0 0 2 3 1 Kelantan 1.53 12 4 8 0 0 0 1 1 1 2 3 1 Melaka 0.73 8 3 11 4 3 5 3 3 4 4 5 5 N. Sembilan 0.96 30 10 31 7 4 7 5 5 5 5 6 5 Pahang 1.45 7 2 5 6 3 4 3 3 2 2 3 1 Perak 2.28 32 10 14 15 9 7 12 11 5 4 5 2 Terengganu 1.04 2 1 2 3 2 3 3 3 3 1 1 1 P. Pinang 1.49 20 6 13 0 0 0 0 0 0 3 4 2 Sabah 3 28 9 9 22 14 7 12 11 4 8 10 3 Sarawak 2.36 22 7 9 14 9 6 6 6 3 7 9 3 Selangor & W.P 6.43 99 32 15 69 43 11 47 43 7 22 28 3 Kuala Lumpur

CHAPTER 9 NEUROLOGY FACILITIES AND DEVICES Edited by : Dr.Suganthi Chinnasami1 , Dr. Mooi Chin Leong1, Dr. Santhi Datuk Puvanarajah1, Dato’ Dr. Hj. Md. Hanip Rafia1.

With contributions from : Neurophysiology Unit HKL 1 Hospital Kuala Lumpur.

NEUROPHYSIOLOGY SERVICES IN PUBLIC SECTOR IN MALAYSIA The first Neurophysiology unit in Malaysia was set up in 1964 at Kuala Lumpur Hospital with only one staff in charge of the unit. Over the years there has been a gradual increase in the total number of neurophysiology units in various states in Malaysia. Currently, there are about 19 units with 67 trained Medical Assistants. The Clinical Neurophysiology Unit provides standard electroencephalography (EEG) and video-telemetry (VT); nerve conduction studies (NCS) and electromyography (EMG); evoked potentials (EP) which include visual, somatosensory and brainstem auditory evoked response; Transcranial Doppler (TCD); and sleep studies. The unit in HKL also runs a 6 months training programme every year for technologists working in the various neurophysiology units in other major hospitals nationwide since.

Epilepsy is one of the most common neurological conditions affecting at any given time between 0.5% and 1% of the general population in developed country. Most studies of the prevalence of active epilepsy have estimated the figure to be 4 and 10 per 1000. The diagnosis of epilepsy is clinical and rests on the description of the seizure provided by the patient and eyewitnesses. Electroencephalogram (EEG) is the study used to record the electrical activity of the brain and should only be carried out in those patients in whom the symptoms suspicious of epilepsy. In such patients the findings of epileptic abnormalities in the EEG lends weight to the diagnosis and the seizure type may also be clarified. EEGs are often insensitive as more than 50% of patients with epilepsy will have a normal tracing.

Portable EEG recording is done in cases where better detection of the interictal and ictal events may be achieved with prolonged recording using portable equipment and this allows recording to take place in the patient’s usual environment.

Behavioral correlation can be achieved in inpatients by video monitoring during EEG and this is called as Video-EEG telemetry. This investigation is mandatory in the evaluation for Epilepsy Surgery and may be the only way to distinguish epileptic seizures from the nonepileptic events.

Electrodiagnostic (EDX) studies play a key role in the evaluation of patients with neuromuscular disorders. Nerve conduction study and needle electromyography form the core of the EDX study and are often used to diagnose disorders of the nerve and muscles. Performed and interpreted correctly, EDX studies yield critical information about the underlying neuromuscular disorder and allow use of other laboratory tests in an appropriate and efficient manner. The principal goals of every EDX study are to localize the disorder and assess its severity. If the disorder localizes the peripheral nerves (i.e. neuropathic), EDX studies often yield further key information, including the fiber types involving the underlying pathophysiology and the temporal course of the disorder.

Polysomnography (PSG) is a diagnostic test during which a number of physiological variables are measured and recorded during sleep. Information is gathered from all leads and fed into a computer and results in a series of waveform tracings, which enable the technician to visualize the various waveforms, assign a score for the test, and assist in the diagnostic process. The PSG monitors many body functions including brain(EEG), eye movements (EOG), muscle activity or skeletal activation (EMG) heart rhythm (ECG), and breathing function or respiratory effort during sleep. PSG is useful in identifying the abnormality in sleep disorders such as dyssomnias and parasomnias. 31 Transcranial Doppler ultrasound (TCD) is used in the management of ischemic stroke and subarachnoid haemorrhage. In ischemic stroke, TCD can detect any stenosis in the intracranial arteries (anterior and posterior circulation) and also the degree of stenosis. It can indirectly detect internal carotid artery stenosis too. Microemboli in the cerebral arteries can also be detected and this may help in the medical management of the patients. In subarachnoid haemorrhage, TCD is used to evaluate the degree of vasospasm, and this will help the neurosurgeons in determining the subsequent management either medically or surgically. TCD can be used to look for cerebral vasoreactivity and can be used as a supplementary investigation in brain death. It is also used as a screening tool for PFO looking for emboli during bubble contrast injection in the peripheral vein. A possible new indication for TCD is sonothrombolysis, increasing the recanalisation rate of thrombosed arteries in acute stroke when used together with rtPA. This is still being researched.

The data collected from the previous MOH and private survey regarding the neuromedical devices are not complete and under reported. This is most likely secondary to poor response from the concerned units. The data for the Selangor state should be separated from the Federal Territory as there are 3 federal states currently which are Kuala Lumpur, Labuan and Putrajaya. This will show a better picture of the current statistics. The Nerve Conduction Velocity measurement system and EMG machine should be tabulated as a single medical device in the statistics instead of reporting it as two separate devices because both tests are done in the same machine. Till today there are no Ambulatory EEG services in Malaysia, which will enable patient to continue with their daily living activities. There should be data survey for DBS (deep brain stimulation) for Parkinson’s disease management, PET/SPECT imaging services in Malaysia, Depth Electrode monitoring for epilepsy, availability of Genetic studies for hereditary Neurological diseases as well as HLA B 1502 allele testing for all patients started on Carbamazepine as well as Aquaporine a-4 testing for NMO patients.

The public sector data is corrected up to date. However the private sector data is dependant on voluntary and accurate submission of the statistics reported and therefore its difficult to verify and comment. In summary this chapter shows the importance of the neurophysiology units in providing diagnostic studies for the increasing work-up demand in the discipline of Neurology.

The tables below show the number of neurophysiology units and the diagnostic equipments available in Malaysia in year 2007.

Table 1: Available Therapeutic and Diagnostic Facilities in Neurology

Neurophysiology Unit No in million No % pmp Malaysia 26.64 24 100 1

Sector Public - 21 87 Private - 3 13

State Johor 3.17 1 4 0 Kedah & Perlis 2.11 1 4 0 Kelantan 1.53 1 4 1 Melaka 0.73 1 4 1 N. Sembilan 0.96 1 4 1 Pahang 1.45 2 8 1 Perak 2.28 1 4 0 Terengganu 1.04 1 4 1 Pulau Pinang 1.49 3 13 2 Sabah 3 3 13 1 Sarawak 2.36 3 13 1 Selangor & W.P Kuala Lumpur 6.43 6 25 1

32 Table 2: Available Medical Devices in Neurology.

Electro- Ambulatory Electro- Evoked Video Telemetry Population encephalography encephalography Potential (EP) Recording (EEG) machine (EEG) machine system System No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 51 100 2 21 100 1 29 100 1 11 100 0

Sector Public - 28 55 14 67 18 62 8 73 Private - 23 45 7 33 11 38 3 27

State Johor 3.17 2 4 1 1 5 0 1 3 0 0 0 0 Kedah & Perlis 2.11 3 6 1 1 5 0 1 3 0 1 9 0 Kelantan 1.53 1 2 1 1 5 1 7 24 5 2 18 1 Melaka 0.73 3 6 4 2 10 3 0 0 0 0 0 0 N. Sembilan 0.96 1 2 1 1 5 1 1 3 1 0 0 0 Pahang 1.45 2 4 1 0 0 0 1 3 1 1 9 1 Perak 2.28 5 10 2 1 5 0 2 7 1 0 0 0 Terengganu 1.04 1 2 1 1 5 1 1 3 1 0 0 0 P. Pinang 1.49 9 18 6 3 14 2 5 17 4 1 9 1 Sabah 3 4 8 1 1 5 0 1 3 0 1 9 0 Sarawak 2.36 3 6 1 1 5 0 0 0 0 1 9 0 Selangor & W.P 6.43 17 33 3 8 38 1 9 31 1 4 36 1 Kuala Lumpur

Electromyography Population Nerve Conduction Velocity (NCV) Measurement System (EMG) machine EMG/NCS EP/EMG/NCS NMDS Data (Sourced from (Sourced from Expert Panel) Expert Panel) No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 36 100 1 27 100 1 4 - - 17 - -

Sector Public - 20 56 18 67 - 4 - 17 - Private - 16 44 9 33 - ND - ND -

State Johor 3.17 2 6 1 1 4 0 0 0 0 1 6 0 Kedah & 2.11 0 0 0 0 0 0 1 25 0 0 0 0 Perlis Kelantan 1.53 7 19 5 7 26 5 0 0 0 1 6 1 Melaka 0.73 2 6 3 0 0 0 0 0 0 1 6 1 N. Sembilan 0.96 1 3 1 1 4 1 0 0 0 1 6 1 Pahang 1.45 1 3 1 1 4 1 0 0 0 2 12 1 Perak 2.28 2 6 1 2 7 1 0 0 0 1 6 0 Terengganu 1.04 1 3 1 1 4 1 0 0 0 1 6 1 P. Pinang 1.49 5 14 3 4 15 3 0 0 0 1 6 1 Sabah 3 2 6 1 1 4 0 1 25 0 3 18 1 Sarawak 2.36 1 3 0 0 0 0 0 0 0 0 0 0 Selangor & W.P 6.43 12 33 2 9 33 1 2 50 0 5 29 1 Kuala Lumpur

33 Population Transcranial Doppler NMDS Data No in million No % pmp Malaysia 26.64 7 100 0

Sector Public - 4 57 Private - 3 43

State Johor 3.17 0 0 0 Kedah & Perlis 2.11 0 0 0 Kelantan 1.53 0 0 0 Melaka 0.73 0 0 0 Negeri Sembilan 0.96 0 0 0 Pahang 1.45 0 0 0 Perak 2.28 0 0 0 Terengganu 1.04 0 0 0 Pulau Pinang 1.49 1 14 1 Sabah 3 1 14 1 Sarawak 2.36 0 0 0 Selangor & W.P Kuala Lumpur 6.43 5 71 1

34 CHAPTER 10 PSYCHIATRY FACILITIES AND DEVICES

Expert Panel Members Chairperson : Dato’ Dr. Suarn Singh1

Members: Dr. Siti Nor Aizah Ahmad2 (Author), Dr. Hj. Mohd Rasidi M. Saring3, Dr. Hj. Mohd Daud Dalip4, Prof. Dr. Mohd Fadzillah Abdul Razak5

1 Hospital Bahagia Ulu Kinta, 2 Hospital Kuala Lumpur, 3 Hospital Sultanah Bahiyah, 4 Hospital Mesra, 5 Universiti Malaysia Sarawak

REPORT Mental health disorders are diverse spectrum of diseases encompassing alterations in thinking, mood and behaviour. The prevalence of mental health disorders among Malaysians is 10.7% [1]; and ranked fourth as the leading cause of burden of disease-by-disease categories [2]. The novel discoveries and rapid advances in understanding psychiatric disorders in the last few decades catalyzed the changing structures in the treatment modalities, management and delivery of mental health services. The challenging issue is to ensure the services and facilities are equally available and accessible to all citizens.

Since the era of deinstitutionalization, the psychiatric-related rehabilitation services gradually developed into broad categorization of hospital-based and community-based services. The day care centers and training shelter workshop constitute the hospital-based rehabilitation services; whereas psychosocial rehabilitation centers and psychiatric nursing homes are facilities based in the community.

The number of facilities seems fairly equally distributed in hospital and community. This concurs with the direction in mental health service to deliver and develop more community mental health facilities. However, the distributions of these facilities are not uniform throughout the country. This could reflect that specialized psychiatric rehabilitation expertise and service are currently only available in certain states. In comparison, the percentage of service contact in community mental health service in Australia was at least 50%; and it reached 98% in certain states [3].

The hospital-based facilities form 53.5% of the total available facilities. However, 94% of the hospital- based facilities are manned by the public sector. All states in Malaysia have at least 1 day care center except Melaka, Pahang and Perlis. The training and shelter workshops are only available in 6 states. The psychosocial rehabilitation centers and psychiatric nursing homes are entirely run by public sector.

It must be noted that once the Mental Health Act 2001 is enforced, the available therapeutic and diagnostic facilities will have to be recategorized into the 3 facilities as provided for in the said Act. The facilities are as follows: “Psychiatric Hospital” (means a government psychiatric hospital or a private psychiatric hospital including a gazetted private psychiatric hospital) “Psychiatric Nursing Home” (means a government psychiatric nursing home or a private psychiatric nursing home, and includes a gazetted private psychiatric nursing home) “Community Mental Health Centre” (means a government community mental health centre or a private community mental health centre, and includes a gazetted private community mental health centre)

35 Although its exact mechanism of action is still unknown, electroconvulsive therapy is an effective treatment modality to achieve rapid and short-term improvement in especially severe depression, severe mania and catatonia [4]. This device is widely available nationwide, mainly in hospitals, but also available in private practice (13%). Its use in England is less, probably attributed to better antidepressants and psychotherapeutic interventions [5]. It is a safe treatment but its adverse effect resulting in cognitive impairment and retrograde amnesia which may happen to some patients, is a significant concern.

Table 1: Available Diagnostic and Therapeutic Facilities in Psychiatry

Hospital-based rehabilitation Community-based rehabilitation facilities facilities Population Training Psychosocial Psychiatric Day Care Centre and Shelter Rehab. Centre Nursing Home Workshop No in million No % pmp No % pmp No % pmp No % pmp

Malaysia 26.64 16 100 1 7 100 0 6 100 0 5 100 0

Sector Public - 15 94 7 100 6 100 5 100 Private - 1 6 0 0 0 0 0 0

State Johor 3.17 3 19 1 1 14 0 1 17 0 2 40 1

Kedah & Perlis 2.11 1 6 0 0 0 0 0 0 0 0 0 0

Kelantan 1.53 1 6 1 0 0 0 1 17 1 0 0 0 Melaka 0.73 0 0 0 0 0 0 0 0 0 0 0 0

N. Sembilan 0.96 2 13 2 0 0 0 1 17 1 0 0 0

Pahang 1.45 0 0 0 1 14 1 0 0 0 0 0 0 Perak 2.28 1 6 0 1 14 0 1 17 0 0 0 0 Terengganu 1.04 1 6 1 0 0 0 1 17 1 0 0 0 P. Pinang 1.49 1 6 1 0 0 0 0 0 0 0 0 0 Sabah 3 0 0 0 1 14 0 0 0 0 0 0 0 Sarawak 2.36 2 13 1 1 14 0 0 0 0 3 60 1 Selangor & W.P 6.43 4 25 1 2 29 0 1 17 0 0 0 0 Kuala Lumpur

36 Table 2 Available Medical Devices in Psychiatry

Population Electroconvulsive Therapy (ECT) machine No in million No % pmp Malaysia 26.64 45 100 2

Sector Public - 39 87 - Private - 6 13 -

State Johor 3.17 3 7 1 Kedah & Perlis 2.11 3 7 1 Kelantan 1.53 4 9 3 Melaka 0.73 1 2 1 Negeri Sembilan 0.96 1 2 1 Pahang 1.45 2 4 1 Perak 2.28 6 13 3 Terengganu 1.04 1 2 1 Pulau Pinang 1.49 7 16 5 Sabah 3 2 4 1 Sarawak 2.36 6 13 3 Selangor & W.P. Kuala Lumpur 6.43 9 20 1

References: 1. The National Health Morbidity Survey, 1996. 2. Division of Burden of Disease, Institute for Public Health, Malaysian Bureau of Disease and Injury Study in Health Prioritisation: Burden of Disease Approach.2004, Ministry of Health Malaysia 3. Australian Institute of Health and Welfare (AIHW) 2008. Mental health services in Australia 2005–06. Mental health series no. 10. Cat no. HSE 56. Canberra: AIHW. 4. National Institute for Clinical Excellence, United Kingdom (2003) 5. Royal College of Psychiatrists, United Kingdom (2008)

CHAPTER 11 CARDIOLOGY AND CARDIOTHORACIC SURGERY FACILITIES AND DEVICES Edited by: Dr. Aizai Azan1

With contributions from: Dr. Alan Yean Yip Fong2, Dr. Chong Wei Peng3, Dr. Ernest Ng4, Dr. Faisal B. Ismail1,

Co-contributors: Prof. Dr. Sim Kui Hian2, Dr. Ong Tiong Kiam2

1 Institut Jantung Negara, 2 Hospital Umum Sarawak, 3 Pusat Perubatan Universiti Malaya, 4 Hospital Serdang

REPORT In 2007, there were 73 dedicated coronary care units (CCU) reported in Malaysia. There were 36 cardiac catheterization laboratories, 47 echocardiography laboratories and 3 invasive electrophysiology laboratories. There was a single heart transplant unit located in the Klang Valley, which is complemented by all the acquired left ventricular assist devices (LVADs) in the country. They were 16 cardio- pulmonary rehabilitation programmes, which were not well represented nationwide.

Table 1: Available Therapeutic and Diagnostic Facilities in Cardiology and Cardiothoracic Surgery

Echocardiography Cardio- Coronary Care Electrophysiology (Non-Invasive Pulmonary Population Unit (CCU) Laboratory Cardiology) Rehabilitation Laboratory Programme No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 73 100 3 3 100 0 47 100 2 16 100 1

Sector Public - 41 56 - 1 33 22 47 12 75 Private - 32 44 - 2 67 25 53 4 25

State Johor 3.17 5 7 2 0 0 0 4 9 1 1 6 0 Kedah & 2.11 5 7 2 0 0 0 3 6 1 2 13 1 Perlis Kelantan 1.53 3 4 2 0 0 0 3 6 2 1 6 1 Melaka 0.73 4 5 5 0 0 0 5 11 7 1 6 1 N. Sembilan 0.96 4 5 4 0 0 0 3 6 3 0 0 0 Pahang 1.45 4 5 3 0 0 0 1 2 1 1 6 1 Perak 2.28 7 10 3 0 0 0 4 9 2 2 13 1 Terengganu 1.04 1 1 1 0 0 0 1 2 1 1 6 1 Pulau Pinang 1.49 9 12 6 1 33 1 5 11 3 0 0 0 Sabah 3 4 5 1 0 0 0 5 11 2 2 13 1 Sarawak 2.36 5 7 2 0 0 0 3 6 1 1 6 0 Selangor & W.P. 6.43 22 30 3 2 67 0 10 21 2 4 25 1 Kuala Lumpur

39 Cardiac Invasive Cardiac Transplant Population Catheterization Cardiovascular Lab Unit Laboratory (Cathlab) No in million No % pmp No % pmp No % pmp Malaysia 26.64 36 100 1 9 100 0 1 100 0

Sector Public - 28 78 - 4 44 0 0 Private - 8 22 - 5 56 1 100

State Johor 3.17 2 6 1 1 11 0 0 0 0 Kedah & Perlis 2.11 1 3 0 0 0 0 0 0 0 Kelantan 1.53 2 6 1 1 11 1 0 0 0 Melaka 0.73 3 8 4 2 22 3 0 0 0 Negeri Sembilan 0.96 1 3 1 0 0 0 0 0 0 Pahang 1.45 1 3 1 0 0 0 0 0 0 Perak 2.28 1 3 0 0 0 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 6 17 4 2 22 1 0 0 0 Sabah 3 1 3 0 1 11 0 0 0 0 Sarawak 2.36 3 8 1 1 11 0 0 0 0 Selangor & W.P. 6.43 15 42 2 1 11 0 1 100 0 Kuala Lumpur

Regarding the actual medical devices recorded, data was obtained for numbers of ambulatory blood monitoring system, ECG telemetry system, Holter system and Electrophysiology monitoring system. These devices were well represented nationwide. For invasive support systems, intra-aortic balloon pumps and heart-lung bypass units were located at facilities, which offered interventional cardiology and cardiac surgery procedures. Other non-invasive diagnostic devices data were obtained for Doppler (vascular) machines, echocardiography systems and transoesophageal echocardiography systems. In the main, these non-invasive devices were more commonly available compared to the invasive systems.

40 Table 2: Available Medical Devices in Cardiology and Cardiothoracic Surgery.

Ambulatory Electrophysiology Blood Pressure ECG Telemetry Population Holter system monitoring Monitoring System system System No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 217 100 8 97 100 4 87 100 3 42 100 2

Sector Public - 38 18 67 67 29 33 21 50 Private - 179 82 32 33 58 67 21 50

State Johor 3.17 17 8 5 6 6 2 4 5 1 10 23 3 Kedah & Perlis 2.11 2 1 1 3 3 1 3 3 1 0 0 0 Kelantan 1.53 1 0 1 0 0 0 4 5 3 0 0 0 Melaka 0.73 3 1 4 0 0 0 6 7 8 0 0 0 N. Sembilan 0.96 15 7 16 0 0 0 3 3 3 2 5 2 Pahang 1.45 9 4 6 2 2 1 3 3 2 5 12 3 Perak 2.28 5 2 2 1 1 0 5 6 2 1 2 0 Terengganu 1.04 2 1 2 4 4 4 0 0 0 0 0 0 Pulau Pinang 1.49 17 8 11 19 19 13 15 17 10 9 21 6 Sabah 3 8 4 3 0 0 0 6 7 2 3 7 1 Sarawak 2.36 2 1 1 4 4 2 6 7 3 0 0 0 Selangor & W.P 6.43 136 62 21 58 59 9 32 36 5 12 28 2 Kuala Lumpur

Extra-Corporeal Intra-aortic Left Ventricular Membrane Heart-Lung Population Balloon Pump Assist Device Oxygenator Bypass Unit (IABP) Machine (LVAD) (ECMO) Machine No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 1 100 0 62 100 2 32 100 1 1 100 0

Sector Public - 0 0 19 31 10 30 0 0 Private - 1 100 43 69 22 70 1 100

State Johor 3.17 0 0 0 7 11 2 3 9 1 0 0 0 Kedah & Perlis 2.11 0 0 0 2 3 1 1 3 0 0 0 0 Kelantan 1.53 0 0 0 5 8 3 1 3 1 0 0 0 Melaka 0.73 0 0 0 4 6 5 2 6 3 0 0 0 N. Sembilan 0.96 0 0 0 0 0 0 0 0 0 0 0 0 Pahang 1.45 0 0 0 2 3 1 0 0 0 0 0 0 Perak 2.28 1 100 0 1 2 0 1 3 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 0 0 0 12 19 8 8 25 5 0 0 0 Sabah 3 0 0 0 2 3 1 1 3 0 0 0 0 Sarawak 2.36 0 0 0 3 5 1 4 13 2 0 0 0 Selangor & W.P 6.43 0 0 0 24 39 4 11 34 2 1 100 0 Kuala Lumpur

41 Trans- Intravascular Doppler Echocardiography Oesophageal Population Ultrasound machine system Echocardiogr. (IVUS) machine (TEE) system No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 30 100 1 153 100 8 45 100 2 7 100 0

Sector Public - 21 70 66 43 21 47 3 43 Private - 9 30 87 57 24 53 4 57

State Johor 3.17 1 3 0 7 5 2 3 7 1 1 14 0 Kedah & Perlis 2.11 0 0 0 10 7 5 3 7 1 0 0 0 Kelantan 1.53 1 3 1 10 7 7 1 2 1 0 0 0 Melaka 0.73 2 7 3 7 5 10 2 4 3 1 14 1 N. Sembilan 0.96 0 0 0 6 4 6 0 0 0 0 0 0 Pahang 1.45 1 3 1 5 3 3 1 2 1 0 0 0 Perak 2.28 1 3 0 10 7 4 2 4 1 0 0 0 Terengganu 1.04 0 0 0 2 1 2 0 0 0 0 0 0 Pulau Pinang 1.49 5 17 3 17 10 11 9 20 6 0 0 0 Sabah 3 1 3 0 11 7 4 1 2 0 0 0 0 Sarawak 2.36 0 0 0 12 8 5 9 20 4 1 14 0 Selangor & W.P 6.43 18 60 3 56 36 9 14 31 2 4 57 1 Kuala Lumpur

Commentary • Concentration of services and devices in the Klang Valley. • Despite the wide availability of coronary care units, there is a relative lack of cardio-pulmonary rehabilitation programmes. • Interventional electrophysiology laboratories are a very specialized area of Cardiology and resources are limited to a few centres. • We note that there are more heart-lung bypass units in the private sector. • Current data not available for implantable cardiac devices eg pacemakers, defibrillators and cardiac heart valves. • More detailed information on the cardiac surgery devices and facilities will be available in the future. • More detailed information on non-invasive devices used in cardiology diagnostics to be available in the future eg treadmill machines and tilt table devices. • National registries, concentrated at tertiary, and hospital-based, will provide targeted information at their respective levels eg Acute Coronary Syndrome, cardiac bypass surgery and percutaneous coronary intervention.

42 CHAPTER 12 RESPIRATORY FACILITIES AND DEVICES

Edited by : Dato’ Dr. Abdul Razak Abdul Mutalif1

With contributions from : Ass. Prof. Dr. Roslina Abdul Manap2, Dr. Ashari Yunus3, Dr. Norhaya Mohd. Razali4, Ass. Prof. Dr. How Soon Hin5

1 Hospital Pulau Pinang, 2 Pusat Perubatan Universiti Kebangsaan Malaysia, 3 Institut Perubatan Respiratori, 4 Hospital Sultanah Zahirah, 5 Universiti Islam Antarabangsa Malaysia, Kuantan

REPORT The National Medical Devices Survey (NMDS), a service initiated and supported by the Ministry of Health, gives complete information on the availability of devices and services in all states in Malaysia. This information is very important for future planning and financing of equipment and manpower. As can be seen later, some states have more manpower and equipment when compared to others. These discrepancies can be due to availability of trained doctors and facilities in some states and none in the others. The data available in this survey can also aid in clinical and epidemiological research.

Data on the availability of therapeutic and diagnostic facilities shows some variations in the public and private sector. With the public hospitals having problems in space and patient load, there is no specific High Dependency Wards for respiratory cases. Almost all public hospitals use general intensive care units (ICU) to treat respiratory cases. The public hospitals however are well equipped with pulmonary physiology laboratories and sleep laboratories (Table 1).

Lung transplantation is a very new service provided by the Malaysian hospital. Only one hospital, National Heart Center with the collaboration of the Institute of Respiratory Medicine, screens cases and performs surgery. On the other hand, smoking cessation is a very well established activity in many health clinics and some public hospitals. A total of one hundred centers carry out this service. This is not enthusiasm of providing service is not noticed in the field of Pulmonary Rehabilitation, as only four public hospital provide it. This is probably due to lack of manpower in the physiotherapy units (Table 1).

Medical devices in the respiratory medicine are well equipped in the public hospitals all over Malaysia. The commitment of the Health Ministry in early diagnosis of COPD is noted in the availability of spirometers, thrice higher then in the private hospitals. This is due to its cheap costs now and easier to use devices. Almost all states have at least one polysomnograph system in their hospitals and some also have portable somnograph machines (Table 2). Body box is a very specialized device and very costly. It is available in most regional public hospitals. Broncho-videoscope systems are freely available in both public and private hospitals. This device is the most important equipment for diagnosis of several lung diseases, like cancers, infections and parenchymal lung disorders. Medical pleuroscope is also a new technology, done by physicians in the wards; this is in all public hospitals. In the private hospitals, rigid scopes were used by surgeons both for thoracoscopy and bronchoscopy for diagnostic and therapeutic procedures, done sometimes by surgeons. This is only done in some public hospitals and not yet available in private hospitals. BiPAP and CPAP systems are used in many public and private hospitals in the treatment of COPD and obstructive apneas.

This report is done with the data provided by the contributors from all states. Some of the states cannot obtain accurate data from all hospitals, especially in the private hospitals. The future survey should look into other ways and methods of obtaining better information on the devices and services in the field of Respiratory Medicine.

43 Table 1: Available Therapeutic and Diagnostic Facilities in Respiratory Medicine

High Dependency Bronchoscopy Respiratory Sleep Population (Respiratory) Suite Laboratory Laboratory Ward No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 24 100 1 34 100 1 15 100 1 16 100 1

Sector Public - 9 38 24 71 13 87 9 56 Private - 15 62 10 29 2 13 7 44

State Johor 3.17 3 12 1 2 6 1 1 7 0 1 6 0 Kedah & Perlis 2.11 1 4 0 2 6 1 1 7 0 1 6 0 Kelantan 1.53 0 0 0 1 3 1 0 0 0 0 0 0 Melaka 0.73 1 4 1 1 3 1 0 0 0 1 6 1 N. Sembilan 0.96 2 8 2 2 6 2 1 7 1 0 0 0 Pahang 1.45 0 0 0 2 6 1 2 13 1 1 6 1 Perak 2.28 3 12 1 4 12 2 3 20 1 1 6 0 Terengganu 1.04 0 0 0 1 3 1 1 7 1 1 6 1 Pulau Pinang 1.49 4 17 3 5 15 3 3 20 2 2 13 1 Sabah 3 1 5 0 5 15 1 1 7 0 1 6 0 Sarawak 2.36 1 5 0 2 6 1 0 0 0 1 6 0 Selangor & W.P. 6.43 8 33 1 7 21 1 2 13 0 6 38 1 Kuala Lumpur

Smoking Cessation Pulmonary Population Lung Transplant Unit Centre Rehabilitation Unit

No in million No % pmp No % pmp No % pmp

Malaysia 26.64 1 100 0 12 100 9 6 100 0

Sector Public - 1 100 12 100 6 100 Private - 0 0 0 0 0 0

State Johor 3.17 0 0 0 2 17 1 0 0 0 Kedah & Perlis 2.11 0 0 0 1 8 0 0 0 0 Kelantan 1.53 0 0 0 1 8 1 0 0 0 Melaka 0.73 0 0 0 1 8 1 0 0 0 Negeri Sembilan 0.96 0 0 0 0 0 0 0 0 0 Pahang 1.45 0 0 0 1 8 1 1 17 1 Perak 2.28 0 0 0 1 8 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 0 0 0 0 0 0 1 17 1 Sabah 3 0 0 0 1 8 0 1 17 0 Sarawak 2.36 0 0 0 1 8 0 0 0 0 Selangor & W.P. 6.43 1 100 0 3 25 0 3 50 0 Kuala Lumpur

44 Table 2: Available Medical Devices in Respiratory Medicine

Pneumo- Total Portable Population Spirometer tacography Polysomnograph Polysomnograph Machine System Machine No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 94 100 3 5 100 0 19 100 1 5 100 0

Sector Public - 71 76 5 100 14 74 5 100 Private - 23 24 0 0 5 26 0 0

State Johor 3.17 5 5 2 0 0 0 0 0 0 0 0 0 Kedah & Perlis 2.11 23 25 11 1 20 0 1 5 0 1 20 0 Kelantan 1.53 6 6 4 0 0 0 2 11 1 0 0 0 Melaka 0.73 2 2 3 0 0 0 2 11 3 0 0 0 N. Sembilan 0.96 3 3 3 0 0 0 1 5 1 1 20 1 Pahang 1.45 5 5 3 0 0 0 1 5 1 2 40 1 Perak 2.28 7 7 3 0 0 0 0 0 0 0 0 0 Terengganu 1.04 1 1 1 1 20 1 0 0 0 0 0 0 Pulau Pinang 1.49 6 6 4 2 40 1 1 5 1 0 0 0 Sabah 3 4 4 1 0 0 0 1 5 0 1 20 0 Sarawak 2.36 7 7 3 0 0 0 1 5 0 0 0 0 Selangor & W.P 6.43 25 27 4 1 20 0 9 47 1 0 0 0 Kuala Lumpur

Body Adult Broncho- Adult BIPAP Adult CPAP Population pletysmograph videoscope system system (“body box”) System No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 7 100 0 107 100 4 55 100 2 147 100 6

Sector Public - 7 100 82 77 21 38 72 49 Private - 0 0 25 23 34 62 75 51

State Johor 3.17 0 0 0 4 4 1 5 9 2 9 6 3 Kedah & Perlis 2.11 0 0 0 1 1 0 2 4 1 3 2 1 Kelantan 1.53 0 0 0 5 5 3 1 2 1 11 7 7 Melaka 0.73 0 0 0 8 7 11 10 18 14 9 6 12 N. Sembilan 0.96 0 0 0 4 4 4 2 4 2 7 5 7 Pahang 1.45 1 14 1 12 11 8 2 4 1 9 6 6 Perak 2.28 0 0 0 9 8 4 2 4 1 8 5 4 Terengganu 1.04 1 14 1 5 5 5 0 0 0 2 1 2 Pulau Pinang 1.49 1 14 1 6 6 4 10 18 7 25 17 17 Sabah 3 1 14 0 4 4 1 4 7 1 6 4 2 Sarawak 2.36 0 0 0 5 5 2 2 4 1 13 9 6 Selangor & W.P 6.43 3 43 0 44 41 7 15 27 2 45 31 7 Kuala Lumpur

45 Paediatric BiPAP Paediatric Medical Paediatric CPAP system with Population bronchoscopy Pleurascope Flow Driver Appropriate (rigid) Set Mask No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 7 100 0 41 100 1 10 100 0 18 100 1

Sector Public - 6 86 29 71 7 70 6 33 Private - 1 14 12 29 3 30 12 67

State Johor 3.17 0 0 0 3 7 1 0 0 0 1 6 0 Kedah & Perlis 2.11 1 14 0 5 12 2 1 10 0 0 0 0 Kelantan 1.53 0 0 0 2 5 1 0 0 0 1 6 1 Melaka 0.73 0 0 0 3 7 4 1 10 1 1 6 1 Negeri 0.96 0 0 0 3 7 3 0 0 0 0 0 0 Sembilan Pahang 1.45 1 14 1 2 5 1 3 30 2 0 0 0 Perak 2.28 0 0 0 8 20 4 0 0 0 2 11 1 Terengganu 1.04 1 14 1 1 2 1 0 0 0 0 0 0 Pulau Pinang 1.49 1 14 1 1 2 1 1 10 1 4 22 3 Sabah 3 1 14 0 0 0 0 0 0 0 1 6 0 Sarawak 2.36 0 0 0 0 0 0 0 0 0 2 11 1 Selangor & W.P 6.43 2 29 0 13 32 2 4 40 1 6 33 1 Kuala Lumpur

46 CHAPTER 13 GASTROENTEROLOGY FACILITIES AND DEVICES

Chairperson: Dr. Hj. Rosemi Salleh1

Secretary: Dr. Hjh. Rosaida Hj. Md. Said2

Representative: Y. Bhg. Dato’ Dr. Hj. Muhammad Radzi bin Abu Hassan3, Dr. Sheikh Anwar Abdullah4

Contributors: Dr. Jeyaram Menon 5, Dr. S. Ganesananthan2

1 Hospital Raja Perempuan Zainab II, 2 Hospital Kuala Lumpur, 3 Hospital Sultanah Bahiyah, 4 Pusat Perubatan Universiti Kebangsaan Malaysia, 5 Hospital Queen Elizabeth.

REPORT For the first time in Malaysia, we are able to report national estimates on the devices pertaining to Gastroenterology Units.

Gastroenterology is one of the medical subspecialties which involve a substantial amount of medical devices. These devices cover use for therapeutic as well as diagnostic purposes. The provision of therapeutic and diagnostic facilities in Gastroenterology can be divided into 1) Non-Invasive Gastroenterology Laboratory; and 2) Endoscopy Day Care Unit/Suite. Non-invasive gastroenterology laboratory refers to provision of devices that do not involve endoscopes, for example capsule endoscopic system, manometry and breath test system.

In Malaysia, more services are provided in endoscopy day care units or suites (55). This is in comparison to only 9 non-invasive gastroenterology laboratories available around the country, in Pahang, Sabah, Sarawak and Selangor & Kuala Lumpur. This may be because the expertise/ technologies were not readily available in the past. Now, there are more and more centres providing these non-invasive services, but they are incorporated into the endoscopy day care units or suites. Those with separate non-invasive laboratories were mostly from the private sector. As there are more private health services available in the Klang Valley, this may explain why the most number of non-invasive gastroenterology laboratories were recorded for Selangor & W.P. Kuala Lumpur.

The endoscopy day care units/suites are available in all states except Terengganu. The highest number was recorded by Selangor & W.P. Kuala Lumpur (17) followed by Pulau Pinang (6), with Sarawak, Johor and Kedah & Perlis having the 3rd highest number (5).

The case of Terengganu having no available therapeutic and diagnostic facilities in gastroenterology may not be fully accurate, as the data is based on the feedback provided only. If there is a lack of cooperation or communication between the departments or in the feedback process, there will be under-reported data.

The devices that related to gastroenterology specialty can be divided into: 1. Endoscopes / Gastroenterology devices 2. Invasive 3. Non-invasive

47 1. Endoscopes / Gastroenterology devices Base on the survey done last year (2007), the gastroduodenoscope and colonoscope devices are the most available in Malaysia with the average of 6 and 5 per million population respectively.

Gastroduodenoscope systems have the largest number in the country, which is about 167, followed by 137 colonoscopes.

Other endoscopic devices are 84 duodenoscopes followed by 47 sigmoidoscopes, 16 Endoscopic ultrasound (EUS), 12 enteroscopy and 4 Double Balloon Enteroscopic (DBE) systems.

Majority of these devices are located in Selangor and Wilayah Persekutuan.

Based on the survey, the number of availability is still not enough for screening purposes, for example screening for colorectal cancer.

Other devices such as DBE and EUS are still low in numbers due to the need of special trainings and their usage are still low.

2. Invasive 3. Non-Invasive There are five non-invasive procedures in which four of them are considered relatively newin Malaysia. The newer non-invasive procedures involve the total water perfused low compliance software pneumohydraulic pump with transducers for anorectal and oesophageal manometry, total 24-hour digitrap per recording device, wireless 48 hour bravo pH recording system, GI breath test system and capsule endoscopic system.

The newer non-invasive procedures are technically simpler and easier to do, and may replace some of the invasive procedures. However, the limitations of these tests are costly and need expertise. Thus, the non-invasive tests will not be available in every centre but to the targeted main centre chosen.

Presently, the individual non-invasive procedures that available in Malaysia are as stated below:-

48 Table 1: Available Therapeutic and Diagnostic Facilities in Gastroenterology.

Non-Invasive Endoscopy Day Care Unit/ Population Gastroenterology Suite Laboratory No in million No % pmp No % pmp Malaysia 26.64 100 0 55 100 2

Sector Public - 4 44 22 40 Private - 5 56 33 60

State Johor 3.17 0 0 0 5 9 2 Kedah & Perlis 2.11 0 0 0 5 9 2 Kelantan 1.53 0 0 0 3 5 2 Melaka 0.73 0 0 0 2 4 3 Negeri Sembilan 0.96 0 0 0 4 7 4 Pahang 1.45 2 22 1 3 5 2 Perak 2.28 0 0 0 4 7 2 Terengganu 1.04 0 0 0 0 0 0 Pulau Pinang 1.49 0 0 0 6 11 4 Sabah 3 1 11 0 1 2 0 Sarawak 2.36 1 11 0 5 9 2 Selangor & W.P. Kuala Lumpur 6.43 5 56 1 17 32 3

Table 2: Available Medical Devices in Gastroenterology

Electro- Laser Biliary Total Biliary Mechanical Biliary Population hydraulic Biliary Lithotripter Lithotripter Unit Lithotripter Unit Lithotripter Unit Unit No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 31 100 1 26 100 1 3 100 0 2 100 0

Sector Public - 19 62 15 58 2 67 1 50 Private - 12 38 11 42 1 33 1 50

State Johor 3.17 2 6 1 2 8 1 0 0 0 0 0 0 Kedah & Perlis 2.11 4 13 2 4 15 2 0 0 0 0 0 0 Kelantan 1.53 5 17 3 4 15 3 1 33 1 0 0 0 Melaka 0.73 1 3 1 1 4 1 0 0 0 0 0 0 N. Sembilan 0.96 0 0 0 0 0 0 0 0 0 0 0 0 Pahang 1.45 3 9 2 1 4 1 1 33 1 1 50 1 Perak 2.28 0 0 0 0 0 0 0 0 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 5 16 3 5 19 3 0 0 0 0 0 0 Sabah 3 1 3 0 1 4 0 0 0 0 0 0 0 Sarawak 2.36 4 13 2 3 12 1 1 34 0 0 0 0 Selangor & WP 6.43 6 20 1 5 19 1 0 0 0 1 50 0 Kuala Lumpur

49 Low compliance software pneumohydraulic Wireless 48 External short 24-hr digitrap pump with hour Bravo Population wave biliary per recording transducers for pH recording lithotripter unit device anorectal and system oesophageal manometry No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 1 100 0 7 100 0 8 100 0 2 100 0

Sector Public - 0 0 4 57 6 75 1 50 Private - 1 100 3 43 2 25 1 50

State Johor 3.17 0 0 0 0 0 0 0 0 0 0 0 0 Kedah & Perlis 2.11 0 0 0 1 14 0 1 13 0 0 0 0 Kelantan 1.53 0 0 0 0 0 0 1 13 1 0 0 0 Melaka 0.73 0 0 0 0 0 0 0 0 0 0 0 0 N. Sembilan 0.96 0 0 0 0 0 0 0 0 0 0 0 0 Pahang 1.45 0 0 0 0 0 0 1 13 1 1 50 1 Perak 2.28 0 0 0 0 0 0 0 0 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 1 100 1 3 43 2 2 24 1 1 50 1 Sabah 3 0 0 0 1 14 0 0 0 0 0 0 0 Sarawak 2.36 0 0 0 0 0 0 0 0 0 0 0 0 Selangor & W.P 6.43 0 0 0 2 29 0 3 37 0 0 0 0 Kuala Lumpur

Intestinal Intestinal GI Breath Test Capsule Tract Stenting Tract Stenting Population System Endoscopic System Bouginage: TTS Bouginage: Savary- dilator Guillard dilator No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 8 100 0 6 100 0 46 100 2 32 100 1

Sector Public - 1 13 5 83 34 74 19 59 Private - 7 88 1 17 12 26 13 41

State Johor 3.17 0 0 0 0 0 0 6 13 2 2 6 1 Kedah & Perlis 2.11 0 0 0 1 17 0 6 13 3 3 9 1 Kelantan 1.53 0 0 0 0 0 0 1 2 1 5 16 3 Melaka 0.73 1 13 1 0 0 0 2 4 3 3 9 4 N. Sembilan 0.96 0 0 0 0 0 0 1 2 1 2 6 1 Pahang 1.45 1 13 1 0 0 0 3 7 2 3 9 2 Perak 2.28 2 24 1 0 0 0 1 2 0 3 9 1 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 2 24 1 1 17 1 4 9 3 3 9 2 Sabah 3 1 13 0 0 0 0 2 4 1 1 4 0 Sarawak 2.36 0 0 0 0 0 0 9 20 4 1 4 0 Selangor & W.P 6.43 1 13 0 4 66 1 11 24 2 6 19 1 Kuala Lumpur

50 Video-endoscopic Video-endoscopic Video-endoscopic Video-endoscopic workstation workstation workstation with: workstation with: endoscopic Population with: gastroscope duodenoscope with: enteroscope ultrasound and and appropriate and appropriate and appropriate appropriate accessories accessories accessories accessories No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 167 100 6 84 100 3 12 100 0 16 100 1

Sector Public - 84 50 41 49 4 33 9 56 Private - 83 50 43 51 8 67 7 44

State Johor 3.17 19 11 6 8 10 3 1 8 0 0 0 0 Kedah & Perlis 2.11 12 7 6 9 11 4 0 0 0 1 6 0 Kelantan 1.53 6 4 4 7 8 5 0 0 0 1 6 1 Melaka 0.73 9 5 12 4 5 5 0 0 0 0 0 0 N. Sembilan 0.96 6 4 6 3 4 3 0 0 0 0 0 0 Pahang 1.45 4 2 3 4 5 3 2 17 1 2 13 1 Perak 2.28 14 8 6 6 7 3 1 8 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 20 12 13 9 11 6 0 0 0 1 6 1 Sabah 3 5 3 2 2 2 1 0 0 0 0 0 0 Sarawak 2.36 15 9 6 10 12 4 2 17 1 2 13 1 Selangor & W.P 6.43 57 35 9 22 25 3 6 50 1 9 56 1 Kuala Lumpur

Video-endoscopic workstation with: Video-endoscopic Video-endoscopic Heater probe for double balloon workstation with: workstation (contact dermal Population enteroscopic sigmoidoscope with: colonoscope device) for system and and appropriate and appropriate gastrointestinal appropriate accessories accessories bleed accessories No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 4 100 0 47 100 2 137 100 5 27 100 1

Sector Public - 2 50 19 40 66 48 17 63 Private - 2 50 28 60 71 52 10 37

State Johor 3.17 0 0 0 5 11 2 12 9 4 3 11 1 Kedah & Perlis 2.11 0 0 0 4 9 2 9 7 4 2 7 1 Kelantan 1.53 0 0 0 3 6 2 11 8 7 2 7 1 Melaka 0.73 0 0 0 2 4 3 6 4 8 0 0 0 N. Sembilan 0.96 0 0 0 3 6 3 4 3 4 0 0 0 Pahang 1.45 1 25 1 3 6 2 4 3 3 3 11 2 Perak 2.28 0 0 0 5 11 2 11 8 5 4 15 2 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 0 0 0 1 2 1 16 12 11 1 4 1 Sabah 3 0 0 0 1 2 0 5 4 2 1 4 0 Sarawak 2.36 0 0 0 6 13 3 13 9 6 3 11 1 Selangor & W.P 6.43 3 75 0 14 30 2 46 33 7 8 30 1 Kuala Lumpur

CHAPTER 14 NEPHROLOGY FACILITIES AND DEVICES

Edited by : Dato’ Dr. Zaki Morad1 , Dr. Ong Loke Meng2

With contributions from : Dr. Goh Bak Leong3, Dr. Hooi Lai Seong4, Dr. Lim Yan Ngo5, Dato’ Dr. Rozina Ghazalli2, En. A. Suhaili b. Shahri5, Sr. Lee Day Guat6, Tn. Hj. Mohd Sulaiman B. Dalimi3, Tn Haji Wazir Hussin7, En. Chua Kee Long

1 Ampang Puteri Specialist Hospital,2 Hospital Pulau Pinang, 3 Hospital Serdang, 4 Hospital Sultanah Aminah, 5 Hospital Kuala Lumpur, 6 Pusat Penyelidikan Klinikal HKL, 7 Hospital Tengku Ampuan Rahimah.

INTRODUCTION Nephrology as a distinct specialty developed in this country in the 1970s. From the very beginning, the public image of nephrology was haemodialysis (HD) treatment and the machines associated with it. Both haemodialysis and peritoneal dialysis treatment maintain their pre-eminent place in Nephrology practice because they consume a disproportionate share of the budget. A significant proportion of the cost of care in Nephrology goes to purchasing and maintaining the dialysis machines. The National Renal Registry has captured data on dialysis practice in the country for the last fifteen years. They have data not only on the numbers but also the utility of these machines. Such information is useful in planning for services and as a guide for purchases in the future.

Apart from the HD machines there are other machines that are used in dialysis practice but have not been captured in this first attempt. They include water treatment machines (or more popularly called the Reverse Osmosis machine), dialyzer reprocessor machine, dialyzer rinsing machines and other related equipment. It is hoped that subsequent endeavours will include these machines to give a comprehensive picture of the dialysis program in the country.

Doctors in general do not have deep interest in the workings of these machines. Yet they place their patients regularly under these machines. It is hoped that the Medical Device Directory will spur greater interest amongst doctors and other healthcare providers who regularly use these machines on how these machines work, their cost, their efficient usage and more importantly their impact on the patients’ health.

53 RESULTS Table 1: Available Therapeutic and Diagnostic Facilities in Nephrology

Chronic Haemodialysis Unit Population Peritoneal Dialysis Unit

No in million No % pmp No % pmp Malaysia 26.64 31 100 1 455 100 17

Sector Public - 25 81 146 32 Private - 6 19 309 68

State Johor 3.17 4 10 1 63 14 20 Kedah & Perlis 2.11 1 3 0 32 7 15 Kelantan 1.53 2 7 1 18 4 12 Melaka 0.73 2 7 3 20 4 27 Negeri Sembilan 0.96 2 7 2 19 4 20 Pahang 1.45 2 7 1 17 4 12 Perak 2.28 3 10 1 50 11 22 Terengganu 1.04 1 3 1 10 2 10 Pulau Pinang 1.49 2 7 1 42 9 28 Sabah 3 2 7 1 26 6 9 Sarawak 2.36 1 3 1 29 6 12 Selangor & W.P. Kuala Lumpur 6.43 9 30 1 129 28 20

Table 1 shows the distribution of peritoneal dialysis (PD) and haemodialysis (HD) centres in the country. The information was obtained from the National Medical Device survey and the National Renal Registry (NRR) (1). In the survey the overall response rate was 57% with 66% response from the public sector and 46% from the private sector. The response rate in the NRR was 100%.

The public sector is the major providers of PD while the private sectors the major provider of HD. Twenty-five (80.6%) of the 31 PD units are located in public sector. PD units with both adult and paediatric nephrologists are regarded as separate units. On the other hand, two-thirds of the haemodialysis centres are private (comprising non-governmental organization and HD units in private sector) while 32% (146) are in the public sector.

There is a wide variation in distribution of PD and HD centres in Malaysia. The number of HD centres in each state ranged from 9 to 28 centres per million population (pmp). The states with the lowest population least served were Sabah, Terengganu and Kelantan. Most (71%) of the PD centres are located in west coast states of West Malaysia. Only 3 (9.7%) centres are located in East Malaysia. The dominance of HD over PD can largely explained by the increase in HD centres runned by non- governmental organizations following the introduction of government subsidy for haemodialysis.

54 Table 2: Available Medical Devices in Nephrology

Continuous Renal Haemodialysis Peritoneal Dialysis Population Replacement Therapy machine Cycler (CRRT) machine

No in million No % pmp No % pmp No % pmp Malaysia 26.64 5008 100 188 112 100 4 61 100 2

Sector Public - 1388 28 107 96 44 72 Private - 3620 72 5 4 17 27

State Johor 3.17 730 15 230 6 5 2 4 7 1 Kedah & Perlis 2.11 337 7 160 7 6 3 4 5 1 Kelantan 1.53 143 3 93 1 1 1 3 3 1 Melaka 0.73 219 4 300 3 3 4 4 3 3 Negeri Sembilan 0.96 216 4 225 5 4 5 2 3 2 Pahang 1.45 182 4 126 3 3 2 3 3 1 Perak 2.28 553 11 243 8 7 4 3 5 1 Terengganu 1.04 115 2 111 0 0 0 1 2 1 Pulau Pinang 1.49 472 9 317 8 7 5 8 12 5 Sabah 3 202 4 67 4 4 1 2 3 1 Sarawak 2.36 307 6 130 4 4 2 5 8 2 Selangor & W.P 6.43 1532 31 238 63 56 10 28 47 4 Kuala Lumpur

Table 2 shows the distribution of HD, PD cycler and continuous renal replacement therapy (CRRT) machines.

There were more HD machines (188 pmp) compared with PD cyclers (4 pmp). However the survey included only PD cyclers in health facilities and home based machines for patients on automated PD were not included. There were 5008 (188 pmp) HD machines (range 67 - 317 machines pmp), 112 PD cyclers (range 0 - 10 pmp) and 61 CRRT machines (range 1-5 pmp) in Malaysia. 72.3% of the haemodialysis, 27.9% of CRRT machines but only 4.5% of PD cyclers were located in the private sector.

There was a wide variation of distribution of HD machines among the states in Malaysia. The west coast states of West Malaysia had the highest number of machines. Selangor and Federal Territory had the highest absolute number of HD machines (1532) while Penang was the highest population served (317 pmp). The least served states were Sabah (67 pmp), Kelantan (93 pmp) and Terengganu (111 pmp).

A vast majority (95.5%) of the PD cyclers are located in the public sector. Selangor and the Federal Territory of Kuala Lumpur (FTKL) had the highest number of PD cyclers: 63 (10 pmp). The surveyhowever included only the cyclers located in health facilities and did not include cyclers used at home by patients. Furthermore the number of PD cyclers under estimates the use of peritoneal dialysis as continuous ambulatory peritoneal dialysis does not require the use of PD cycler.

72.1% of CRRT machines are in the public sector with the best served states in west coast of Peninsular Malaysia (Selangor & FTKL, Penang and Melaka). This is not unexpected as CRRT is an expensive modality in the treatment of acute renal failure.

55 Summary This is the first report on the nephrology and urology services available in the country. There may be gaps in the data collected and this be filled with subsequent reports.

HD penetration is better compared with PD in Malaysia. The private sector is the major provider of HD facilities while the public sector is the major provider of PD. There is an inequity in distribution of nephrology facilities in the country with the highest population served in the West Coast of states of West Malaysia (Penang, Selangor & FT and Perak) and the lowest in Sabah, Terengganu and Kelantan. Future planning should include increasing the number of PD centres as the demand for human resource, cost and office space is less.

References 1. 15th report of the Malaysian Dialysis and Transplant Registry 2007.

56 CHAPTER 15 UROLOGY FACILITIES AND DEVICES Authors : Dr. Murali Sundram Abdullah1, Dr. Clarence Lei Chang Moh2

1 Hospital Kuala Lumpur, 2 Normah Medical Centre.

REPORT Response Rates Of the 92 hospitals purported to provide urology services, 73% responded to the survey. To our knowledge, of these 92 hospitals, only 50 have full time resident urologists offering the full range of general urology services. Of these 52 hospitals, roughly 2/3 (37) are private institutions.

Table 1: Available Diagnostic and Therapeutic Facilities in Urology

Renal Transplant Urodynamic Population Stone Center Robotic Centre Center Laboratory

No in million No % pmp No % pmp No % pmp No % pmp

Malaysia 26.64 47 100 2 7 100 0 3 100 0 7 100 0

Sector Public - 12 25 4 57 - 2 67 - 3 43 - Private - 35 75 3 43 - 1 33 - 4 57 -

State

Johor 3.17 4 9 1 0 0 0 0 0 0 1 14 0

Kedah & Perlis 2.11 3 6 1 0 0 0 0 0 0 1 14 0

Kelantan 1.53 1 2 1 0 0 0 0 0 0 0 0 0

Melaka 0.73 3 6 4 0 0 0 0 0 0 1 14 1

Negeri Sembilan 0.96 2 4 2 0 0 0 0 0 0 0 0 0

Pahang 1.45 2 4 1 0 0 0 0 0 0 0 0 0

Perak 2.28 3 6 1 0 0 0 0 0 0 0 0 0

Terengganu 1.04 1 2 1 0 0 0 0 0 0 0 0 0

Pulau Pinang 1.49 6 13 4 0 0 0 0 0 0 0 0 0

Sabah 3 2 4 1 0 0 0 0 0 0 0 0 0

Sarawak 2.36 3 6 1 0 0 0 1 33 0 1 14 0 Selangor & W.P. 6.43 17 36 3 7 100 1 2 67 0 3 43 0 Kuala Lumpur

57 Population Andrology Laboratory

No in million No % pmp Malaysia 26.64 2 100 0

Sector Public - 0 0 Private - 2 100

State Johor 3.17 1 50 0 Kedah & Perlis 2.11 0 0 0 Kelantan 1.53 0 0 0 Melaka 0.73 0 0 0 Negeri Sembilan 0.96 0 0 0 Pahang 1.45 0 0 0 Perak 2.28 0 0 0 Terengganu 1.04 0 0 0 Pulau Pinang 1.49 0 0 0 Sabah 3 0 0 0 Sarawak 2.36 0 0 0 Selangor & W. P. Kuala Lumpur 6.43 1 50 0

Some of the facilities listed under urology suffer from a lack of strict definition and hence the possibility of false reporting.

A stone centre is a stand-alone centre with dedicated facilities for the treatment of all types of urinary stones. The centre should have the full range of endoscopic and percutaneous methods of stone clearance; either possesses or has access to an ESWL machine and should have a resident urologist. This definition may not be applied strictly because some centers have general surgeons who practice urology and some centers have visiting urologists who offer some but not the entire range of urological services.

A renal transplant centre is a stand-alone center that provides a continuum of comprehensive care to patients undergoing kidney transplantations both living related and cadaveric. The service may include monitoring of patients awaiting transplantation, medical and surgical therapies, and follow- up care inclusive of management of immunosuppressive therapy. There are 4 public centers, which do the majority of the transplants, and 3 private centers all of which are in the Klang valley.

A robotic centre is a stand-alone center equipped with capabilities to perform robotic assisted laparoscopic surgical procedures. Possession of a robotic machine must be a perquisite. There are 2 in the public and 1 in the private.

An urodynamic laboratory is a stand-alone center dedicated to performing urodynamic assessments for the diagnosis and management of incontinence, lower urinary tract dysfunctions and prolapses. Possession of a urodynamic machine (with or without fluoroscopy) is a prerequisite. The total of 7 recorded is too small as the public sector alone has 10. Urodynamic machines under the urogynaecologists are not shown here.

An andrology laboratory is a stand-alone center that specifically provides male infertility testing services. It may or may not provide cryopreservation or sperm banking services. Although many hospitals offer hormonal assays and semen analysis and have urologists on staff, it is not clear if this constitutes an andrology laboratory.

58 Table 2: Available Medical Devices in Urology

Extracorporeal Total Extracorporeal Extracorporeal Shockwave Extracorporeal Shockwave Shockwave Lithotripter Population Shockwave Lithotripter Lithotripter (ESWL) with Vital Lithotripter (ESWL) with (ESWL) with Data Monitoring (ESWL) unit Fluoroscopy unit Ultrasound unit Capability No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 70 100 3 22 100 1 27 100 1 20 100 1

Sector Public - 22 31 6 27 10 37 5 25 Private - 48 69 16 73 17 63 15 75

State Johor 3.17 7 10 2 3 14 1 2 7 1 3 15 1 Kedah & Perlis 2.11 6 9 3 1 5 0 2 7 1 2 10 1 Kelantan 1.53 4 6 3 1 5 1 2 7 1 1 5 1 Melaka 0.73 10 14 14 3 14 4 4 15 5 3 15 4 N. Sembilan 0.96 0 0 0 0 0 0 0 0 0 0 0 0 Pahang 1.45 1 1 1 0 0 0 0 0 0 0 0 0 Perak 2.28 2 3 1 0 0 0 2 7 1 0 0 0 Terengganu 1.04 1 1 1 0 0 0 1 4 1 0 0 0 Pulau Pinang 1.49 9 13 6 3 14 2 3 11 2 3 15 2 Sabah 3 4 6 1 1 5 0 2 7 1 1 5 0 Sarawak 2.36 10 14 4 3 14 1 3 11 1 3 15 1 Selangor & W.P 6.43 16 23 2 7 29 1 6 22 1 4 20 1 Kuala Lumpur

Total Intracorporeal Intracorporeal Intracorporeal Population Intracorporeal Lithotripter Unit Lithotripter Unit Lithotripter Unit Lithotripter Unit with Lithoclast with Ultrasound with Laser No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 73 100 3 42 100 2 24 100 1 5 100 0

Sector Public - 25 34 12 29 12 50 2 40 Private - 48 66 30 71 12 50 3 60

State Johor 3.17 8 11 3 4 10 1 3 13 1 0 0 0 Kedah & Perlis 2.11 7 10 3 4 10 2 2 8 1 0 0 0 Kelantan 1.53 6 8 4 3 7 2 3 13 2 0 0 0 Melaka 0.73 5 7 7 3 7 4 2 8 3 0 0 0 N. Sembilan 0.96 2 3 2 1 2 1 1 4 1 0 0 0 Pahang 1.45 4 5 3 1 2 1 1 4 1 1 20 1 Perak 2.28 2 3 1 2 5 1 0 0 0 0 0 0 Terengganu 1.04 2 3 2 1 2 1 1 4 1 0 0 0 Pulau Pinang 1.49 7 10 5 5 12 3 2 8 1 0 0 0 Sabah 3 3 4 1 2 5 1 1 4 0 0 0 0 Sarawak 2.36 7 10 3 3 7 1 2 8 1 1 20 0 Selangor & W.P 6.43 20 27 3 13 31 2 6 25 1 3 60 0 Kuala Lumpur

59 ESWL machine numbers are grossly overestimated probably because of over reporting in the last column (ESWL with vital data monitoring) and this should be left out in future surveys. To our knowledge there are a total of 45 ESWL machines in Malaysia of which only 14 are in the public sector. 40% are located in Selangor & WP area and the rest quite evenly distributed among the other states capitals.

The most common intracorporeal lithotripsy device is the lithoclast followed by the ultrasonic lithotripter. Laser lithotripsy, which is delivered via a flexible fiber, is the latest lithotripsy device.

Uroflowmetry Bladder scan to Total Urodynamic Uroflowmeter in a Population with urodynamic measure residual machine separate toilet machine bladder volume

No in million No % pmp No % pmp No % pmp No % pmp

Malaysia 26.64 21 100 1 16 100 1 31 100 1 16 100 1

Sector Public - 7 33 4 25 14 45 6 38 Private - 14 67 12 75 17 35 10 62

State Johor 3.17 2 10 1 2 13 1 3 10 1 1 6 0 Kedah & Perlis 2.11 2 10 1 2 13 1 2 6 1 2 13 1 Kelantan 1.53 1 5 1 1 6 1 2 6 1 0 0 0 Melaka 0.73 0 0 0 2 13 3 3 10 4 1 6 1 N. Sembilan 0.96 1 5 1 0 0 0 0 0 0 0 0 0 Pahang 1.45 1 5 1 1 6 1 1 3 1 1 6 1 Perak 2.28 0 0 0 0 0 0 1 3 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0

Pulau Pinang 1.49 4 19 3 3 19 2 4 13 3 3 19 2

Sabah 3 0 0 0 0 0 0 1 3 0 1 6 0 Sarawak 2.36 3 14 1 2 13 1 2 6 1 2 13 1 Selangor & W.P 6.43 7 33 1 3 19 0 12 39 2 5 31 1 Kuala Lumpur

The table on urodynamic equipment is flawed. There should be only 3 categories – Bladder scan, Uroflowmetry and Urodynamic machine. The first two are basic urodynamic devices available in most urological centers and the numbers given appear too small whereas the numbers for urodynamic machines (which are mainly found in high volume public centers) are too high.

60 Nephroscope Ureteroscope Ureteroscope Population Resectoscope (rigid) (flexible) (rigid)

No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 95 100 4 56 100 2 23 100 1 79 100 3

Sector Public - 40 42 24 43 9 39 28 35 Private - 55 58 32 57 14 61 51 65

State Johor 3.17 10 11 3 7 13 2 3 13 1 12 15 4 Kedah & Perlis 2.11 6 6 3 5 9 2 1 4 0 6 8 3 Kelantan 1.53 4 4 3 4 7 3 2 8 1 5 6 3 Melaka 0.73 6 6 8 3 5 4 3 13 4 7 9 10 N. Sembilan 0.96 1 1 1 1 2 1 0 0 0 1 1 1 Pahang 1.45 3 3 2 3 5 2 1 4 1 3 4 2 Perak 2.28 8 8 4 3 5 1 0 0 0 2 3 1 Terengganu 1.04 4 4 4 1 2 1 0 0 0 2 3 2 Pulau Pinang 1.49 8 8 5 6 11 4 1 4 1 9 11 6 Sabah 3 4 4 1 2 4 1 0 0 0 3 4 1 Sarawak 2.36 13 15 6 8 14 3 4 17 2 8 10 3 Selangor & W.P 6.43 28 29 4 13 23 2 8 35 1 21 27 3 Kuala Lumpur

Population Cystoscope (flexible) Cystoscope (rigid)

No in million No % pmp No % pmp Malaysia 26.64 62 100 2 124 100 5

Sector Public - 25 40 64 52 Private - 37 60 60 48

State Johor 3.17 6 10 2 19 15 6 Kedah & Perlis 2.11 7 11 3 7 6 3 Kelantan 1.53 3 5 2 5 4 3 Melaka 0.73 4 6 5 6 5 8 Negeri Sembilan 0.96 1 2 1 4 3 4 Pahang 1.45 3 5 2 3 2 2 Perak 2.28 2 3 1 9 7 4 Terengganu 1.04 1 2 1 1 1 1 Pulau Pinang 1.49 8 13 5 12 10 8 Sabah 3 3 5 1 6 5 2 Sarawak 2.36 7 11 3 15 12 6 Selangor & W.P Kuala Lumpur 6.43 17 28 3 37 30 6

61 Endoscopic and percutaneous technology has revolutionized the practice of urology and this is reflected in the various types of endoscopes both rigid and flexible. The rigid cystoscope is the most common because it is also used by the non-urologist. The resectoscope is the most common tool of the urologist (n= 95). The rigid ureteroscope, rigid nephroscope and flexible cystoscope are the workhorses for the urologist and average about 60 in each category. Flexible ureteronephroscopes number 23. Although 2/3 of all hospitals offering the standard urology services are private institutions, the numbers of scopes are distributed almost equally between private and public hospitals reflecting the difference in workload.

Summary There are 50 hospitals offering the full range of urological services with a resident urologist(s). 13 are public and 37 private. Urolithiasis constitutes the main workload of Malaysian urologists and all 50 of these hospitals are considered stone centers with 90% having ESWL machines. Of the 45 ESWL machines in the country, 30% are in public hospitals and 40% are in the Klang Valley. Most of the public urological centers are also urodynamic centers. Transplant and Robotic services are mainly in public hospitals. There are probably another 40 hospitals that offer limited urology services provided by a visiting urologists or a general surgeon with an interest in urology.

The resectoscope is the most common instrument, followed by the flexible cystoscope, rigid ureteroscope and rigid nephroscope. The most common intracorporeal devices are the lithoclast and ultrasonic.

62 CHAPTER 16 DERMATOLOGY FACILITIES AND DEVICES Edited by : Pn Sri Datin Dr. Suraiya H Hussein1, Dr. Rohna Ridzwan2

With contributions from : Dr. Choon Siew Eng3, Dr. Asmah Johar1

1 Kuala Lumpur Hospital MOH, 2 Selayang Hospital MOH, 3 Hospital Tengku Ampuan Aminah MOH

HIGH TECHNOLOGY DEVICES IN DERMATOLOGY SERVICES INTRODUCTION The introduction of medical technology in clinical practice has expanded the Dermatology services from mere office consultation to that of investigative and therapeutic Dermatology services. The medical devices range from simple cryosurgical units to the sophisticated and bulky Phototherapy cabins and Laser surgical machines. Table 1 shows the devices in decreasing order of cost.

Table 1 Dermatology Devices - Indication and Credentialed Operators

Mode of Medical Device Indication of usage Credentialed operator Management 1 Cryosurgical unit Benign skin tumours Therapeutic Trained doctors & nurses Nodular dermatitis Basal cell carcinoma Therapeutic Trained dermatologist 2 Electrosurgical unit Benign skin tumours Therapeutic Trained doctors 3 Iontophoresis Palmar & plantar Hyperhidrosis Interim therapy Doctors and trained physiotherapist 4 Phototherapy unit Full body phototherapy cabin Psoriasis Therapeutic Dermatologists (broad band UVB & UVA) Vitiligo (extensive) and trained Mycosis Fungoides Physiotherapists Others and nurses under Full body phototherapy cabin Psoriasis Therapeutic supervision by (narrow band UVB) Scleredema Vitiligo Dermatologists. Mycosis Fungoides Full body phototherapy cabin Mycosis Fungoides Adjuvant (UVA1) Scleredema therapy Morphoea Hand & feet phototherapy unit Hand & foot psoriasis Therapeutic Hand & feet vitiligo Hand held phototherapy Scalp psoriasis Therapeutic Localized vitiligo PUVA ten (UV lamps) Localized vitiligo Therapeutic Multi tester Unit (UVA & UVB) Investigative 5 Laser surgical unit Carbon dioxide laser system Benign skin tumours Trained Resurfacing of scars Dermatologist Intense pulse light laser Hair removal, resurfacing of scars, Therapeutic system photo rejuvenation & Cosmesis Pigment laser system Hyperpigmented disorders, tattoos, hair removal Vascular laser system Port wine stains, haemangioma, telangiectasia / varices

63 Table 2: Available Therapeutic and Diagnostic Facilities in Dermatology No Data to Date

Table 3: Available Medical Devices in Dermatology CO Laser Other Laser Phototherapy Phototherapy Population 2 system systems UVB PUVA No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 7 100 0 7 100 0 12 100 0 27 100 1

Sector Public - NC - NC - NC - NC - Private - NC - NC - NC - NC -

State Johor 3.17 1 14 0 0 0 0 2 17 1 2 7 1 Kedah & Perlis 2.11 1 14 0 0 0 0 1 8 0 2 7 1 Kelantan 1.53 0 0 0 0 0 0 0 0 0 1 4 1 Melaka 0.73 1 14 1 1 17 1 0 0 1 2 7 3 Negeri Sembilan 0.96 1 14 1 2 33 2 1 8 1 1 4 1 Pahang 1.45 1 0 1 0 0 0 1 8 1 1 4 1 Perak 2.28 0 0 0 0 0 0 1 8 0 2 7 1 Terengganu 1.04 0 0 0 0 0 0 0 0 0 0 0 0 Pulau Pinang 1.49 1 14 1 0 0 0 0 0 0 1 4 1 Sabah 3 0 0 0 0 0 0 1 8 0 1 4 0 Sarawak 2.36 0 0 0 1 17 0 2 17 1 2 7 1 Selangor & W.P 6.43 1 14 0 2 33 0 3 25 0 12 44 2 Kuala Lumpur

Population Cryosurgical Unit Electrosurgical Unit Iontophoresis Unit No in million No % pmp No % pmp No % pmp Malaysia 26.64 38 100 1 26 100 1 14 100 0

Sector Public - NC - NC - NC - Private - NC - NC - NC -

State Johor 3.17 5 13 2 3 12 1 3 21 1 Kedah & Perlis 2.11 4 11 2 4 15 2 3 21 1 Kelantan 1.53 1 3 1 1 4 1 0 0 0 Melaka 0.73 2 5 3 3 12 4 0 0 0 Negeri Sembilan 0.96 2 5 2 2 8 2 1 7 1 Pahang 1.45 2 5 1 1 4 1 0 0 0 Perak 2.28 4 11 2 2 8 1 1 7 0 Terengganu 1.04 2 5 2 1 4 1 0 0 0 Pulau Pinang 1.49 4 11 3 2 8 1 1 7 1 Sabah 3 2 5 1 2 8 1 1 7 0 Sarawak 2.36 5 13 2 2 8 1 1 7 0 Selangor & W.P 6.43 5 13 1 3 12 0 3 21 0 Kuala Lumpur

64 The National Medical Device Survey was conducted by the Clinical Research Center in year 2007. Two hundred and fifty three hospitals were surveyed. The response to the survey is shown in Fig. 1

Fig. 1 National Medical Device Survey 2007 Respondents

Hospital surveyed n=253

Hospital with Hospital with no Dermatology services Dermatology services n=78 n=175

Hospital with Dermatology Hospital with Dermatology services that responded services that did not respond n=47 n=31

MOH & Army Hospitals with Private Hospitals with University Hospitals with Dermatology services Dermatology services Dermatology services n=31 n=13 n=3

Johor Pahang Malacca UMMC n=3 n=1 n=2

Malacca Terengganu Selangor UKM n=1 n=1 n=5

N. Sembilan Kelantan Wilayah USM n=2 n=3 Persekutuan n=1

Selangor Perlis Perak n=5 n=1 n=1

Wilayah Sabah Penang Persekutuan n=3 n=1 n=1

Perak Sarawak Sabah n=3 n=2 n=1

Kedah Penang Sarawak n=4 n=1 n=1

65 The National survey investigation enabled a more comprehensive understanding of the availability and use of dermatological devices both in the public and private sectors. Nevertheless the response rate of only 60.2 % could be improved in the future surveys.

Fig. 2 Malaysian Population Accessibility to Dermatology Medical Devices in Year 2007

PERLIS 2.11 Million

1 4

3 4

KEDAH 1

1 1

PENANG 1 1.49 Million 1 1 1 1 2 4 2 1 2 KELANTAN 1 1 4 2 1.53 Million TERENGGANU 1 1.53 Million PERAK 2.28 Million

PAHANG 1.45 Million 1 1

1 2 1 2 SELANGOR & 1 WILAYAH PERSEKUTUAN 3 12 2.11 Million 5 3 N. SEMBILAN 3 2.36 Million Key : 1 2 1 1 1 2 2 CO2 Laser System 1 1

2 JOHOR Other Laser System 2 MELAKA 3 2.36 Million

2.36 Million 1 2 2 Phototherapy (UVB) 3 2 3 Phototherapy (PUVA)

Cryosurgical Unit

Electrosurgical Unit

Iontophoresis Unit

* The numbers in the figures above denote the quantity of equipment available.

66 1 1

2 2

1 SABAH 2.36 Million

1 2

2 5

1 2 SARAWAK 2.36 Million

The data in this report is limited by the absence of data from stand alone clinics providing Dermatology service which was not surveyed and the under reporting of availability of the device in private hospitals. Nevertheless, the effort by the National Medical Device Survey team has enabled the government as well as the private sector to plan for the future expansion and assure availability of appropriate dermatological devices both in private and public sectors to meet the needs of the Malaysian public and for medical tourism.

CHAPTER 17 OTORHINOLARYNGOLOGY AND AUDIOLOGY FACILITIES AND DEVICES

Authors/Contributors : Prof Madya Dr. Rahmat Omar1, Dato’ Dr. Abdul Majid Md Nasir2, Dr. Junainah Sabirin3, Muhammad Almyzan Awang4, Nor Shahrina Mohd Zawawi4

1 Pusat Perubatan Universiti Malaya, 2 Hospital Kuala Lumpur, 3 Cawangan Penilaian Teknologi Kesihatan, 4 Pusat Perubatan Universiti Kebangsaan Malaysia.

Response Rates Otorhinolaryngology : 47 hospitals and medical centers did not respond to the NMDS survey despite the availability of ORL services. These include 22 within Selangor and Kuala Lumpur, which are expected to be within reach of this survey. The results are expected to change dramatically as more centers respond in the future.

Audiology : 59 hospitals that responded have no audiology services. These include several well- established hospital likes Pusat Pakar Tawakal, Pantai Cheras Medical Center and Hospital PUSRAWI Sdn Bhd. Even high bed strength hospitals like Likas Hospital and Sultan Ismail Hospital, Johor Bahru have no audiology services.

Table 1: Available Therapeutic and Diagnostic Facilities in Otorhinolaryngology and Audiology.

Population Sound Treated Room Speech Lab

No in million No % pmp No % pmp Malaysia 26.64 10 100 0 4 100 0

Sector Public - 4 40 2 50 Private - 6 60 2 50

State Johor 3.17 1 10 0 1 25 0 Kedah & Perlis 2.11 0 0 0 0 0 0 Kelantan 1.53 1 10 1 0 0 0 Melaka 0.73 0 0 0 1 25 1 Negeri Sembilan 0.96 0 0 0 0 0 0 Pahang 1.45 0 0 0 0 0 0 Perak 2.28 0 0 0 0 0 0 Terengganu 1.04 0 0 0 0 0 0 Pulau Pinang 1.49 2 20 1 0 0 0 Sabah 3 1 10 0 0 0 0 Sarawak 2.36 2 20 1 0 0 0

Selangor & W.P. Kuala Lumpur 6.43 3 30 0 2 50 0

69 Figures in the table above reflected under-reporting and does not correspond with the expected availability especially in the city like those within Selangor and W.P.Kuala Lumpur as well as Johor Bahru.

Table 2: Available Medical Devices in Otorhinolaryngology and Audiology.

Auditory Portable Otoacoustic Brainstem Portable Auditory Emission (OAE) Response (ABR) Otoacoustic Population Brainstem Unit Unit Emission Response (ABR) (portable and (portable and (OAE) Unit Unit static) static)

No in million No % pmp No % pmp No % pmp No % pmp

Malaysia 26.64 55 100 2 24 100 1 65 100 2 42 100 2

Sector

Public - 38 69 16 67 45 69 30 71

Private - 17 31 8 33 20 31 12 29

State

Johor 3.17 4 7 1 2 8 1 7 11 2 4 10 1

Kedah & Perlis 2.11 2 4 1 1 4 0 3 5 1 2 5 1

Kelantan 1.53 3 5 2 1 4 1 7 11 5 5 12 3

Melaka 0.73 2 4 3 1 4 1 2 3 3 2 5 3

Negeri Sembilan 0.96 3 5 3 1 4 1 3 5 3 2 5 2

Pahang 1.45 4 7 3 1 4 1 4 6 3 3 7 2

Perak 2.28 4 7 2 3 13 1 3 5 1 3 7 1

Terengganu 1.04 2 4 2 1 4 1 2 3 2 2 5 2

Pulau Pinang 1.49 7 13 5 4 17 3 6 9 4 5 12 3

Sabah 3 3 5 1 2 8 1 3 5 1 1 2 0

Sarawak 2.36 3 5 1 1 4 0 4 6 2 2 5 1

Selangor & W.P 6.43 18 34 3 6 25 1 21 31 3 11 25 2 Kuala Lumpur

70 Functional Audiometer Portable Endoscopic Microdebrider Population (static and Audiometer Sinus Surgery System portable) system (FESS) No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 22 100 1 65 100 2 40 100 2 32 100 1

Sector Public - 12 55 31 48 25 62 19 59 Private - 10 45 34 52 15 38 13 41

State Johor 3.17 2 8 1 5 8 2 3 7 1 2 6 1 Kedah & Perlis 2.11 0 0 0 5 8 2 3 7 1 3 9 1 Kelantan 1.53 1 5 1 4 6 3 3 7 2 5 16 3 Melaka 0.73 1 5 1 6 9 8 1 3 1 3 9 4 N. Sembilan 0.96 1 5 0 2 3 2 1 3 1 2 6 1 Pahang 1.45 2 8 1 3 5 2 2 5 1 3 9 2 Perak 2.28 1 5 0 6 9 3 10 25 4 3 9 1 Terengganu 1.04 1 5 0 1 2 1 1 3 1 0 0 0 Pulau Pinang 1.49 3 14 2 7 11 5 6 15 4 3 9 2 Sabah 3 2 8 1 4 6 1 0 0 0 1 4 0 Sarawak 2.36 3 14 1 5 8 2 3 7 1 1 4 0 Selangor & W.P 6.43 5 23 1 17 25 3 7 18 1 6 19 1 Kuala Lumpur

ORL Endoscopic Camera System Population (flexible and rigid) No in million No % pmp Malaysia 26.64 142 100 5

Sector Public - 80 56 Private - 62 44

State Johor 3.17 10 7 3 Kedah & Perlis 2.11 6 4 3 Kelantan 1.53 8 6 5 Melaka 0.73 7 5 10 Negeri Sembilan 0.96 2 1 2 Pahang 1.45 7 5 5 Perak 2.28 13 9 6 Terengganu 1.04 1 1 1 Pulau Pinang 1.49 20 14 13 Sabah 3 8 6 3 Sarawak 2.36 13 9 6 Selangor & W.P Kuala Lumpur 6.43 47 33 7

As expected, there were more FESS systems as compared to microdebrider systems as the former is more commonly used for sinus surgery. However the microdebrider system is gaining more acceptance as technology advances.

CHAPTER 18 OPHTHALMOLOGY AND OPTOMETRY FACILITIES AND DEVICES Edited by : Datin Dr. Mariam Ismail1, Dr. Goh Pik Pin1

With contribution from : Dato’ Dr. Balaravi Pillai2; Dato’ Dr.Vasantha Kumar3, Dr. Mutalib Othman4, Dr. Jamalia Rahmat5

1 Selayang Hospital, 2 Ipoh Hospital, 3 Hospital Tengku Ampuan Afzan, 4 Queen Elizabeth Hospital, 5 Kuala Lumpur Hospital

INTRODUCTION Ophthalmology and optometry services are amongst the highly technology dependent services, where devices are used in the examination of patients, investigation and procedures to arrive at a diagnosis and plan patient management. In addition, devices in these fields are being revised, improved with new features and newer technology introduced all the time. Results of the first 2007 National Medical Device Survey have a poor response rate. Out of the 256 health care providers, 141 (55.1%) responded to the survey. Response rate was slightly higher among Ministry of Health (MOH only) facilities, 60.6% as compared to private facilities (48.7%). Among the 141 respondents, 95(67.4%) provide and 46 (32.6%) did not provide ophthalmology and optometry service. Hence, the 2007 survey findings are not really representative and only findings on essential facilities and devices that are considered fairly reliable are reported. A subsequent phone survey was conducted from 21 July to 25 July 2008 on 36 MOH ONLY Ophthalmology departments and 9 district hospitals with Optometrists but without Ophthalmologist. These data collated by the expert panel replaced the NMDS data where they were deemed necessary.

Results Therapeutic and Diagnostic Facilities Of the 95 centres with ophthalmology services that responded, 28 (29.5%) have an eye casualty clinic, a clinic which see ‘walk –in’ patients with acute or emergency eye problems. More than half of the eye care facilities have a laser room (53, 55.8%).

Ophthalmology and Optometry Medical Devices Though the survey includes all types of medical devices used in ophthalmology and optometry services, we report only essential devices required to provide eye care service such as A scan and phacoemulsification unit for cataract surgery, imaging such as B scan, fundus camera and Ophthalmic laser systems.

A Scan, B Scan and Phacoemulsification Machine Survey findings indicated that there are 118 A scan, 64 B Scan and 76 phacoemulsification units. The states with the highest number of these devices are Selangor and Wilayah Persekutuan and Penang. The state with the highest number of A and B Scan per million population is Penang whilst Melaka ranks highest for phacoemulsification unit. (Table 2)

73 Fundus camera Survey results showed availability of 40 fundus cameras in ophthalmology clinics that is one fundus camera per million population in Malaysia. Of these, more than half are in the public eye care facilities. The state with the highest number of fundus camera is Selangor and Wilayah Persekutuan and Penang. (Table 2). This survey did not include fundus cameras located at the Ministry of Health Klinik Kesihatan for the screening of diabetic retinopathy.

Ophthalmic Laser System The most common laser machine available is Argon laser (58 units), followed by Nd YAG laser (46 units), Diode laser (26 units) and Endolaser (19 units). Most of these lasers are located in public hospitals. (Table 2)

DISCUSSION / CONCLUSION Data collected from the National Medical Device survey 2007 are incomplete and thus not representative. Effort in getting more complete return with better approach will be done for 2008 survey.

Table 1: Available Therapeutic and Diagnostic Facilities in Ophthalmology and Optometry Specialties.

Eye Casualty Ophthalmology Population Refraction Room Clinic Laser Room

No in million No % pmp No % pmp No % pmp

Malaysia 26.64 28 100 1 53 100 2 - - -

Sector

Public - 22 79 33 62 46 -

Private - 6 21 20 38 ND -

State

Johor 3.17 2 7 1 4 8 1 4 10 1

Kedah & Perlis 2.11 4 14 2 4 8 2 5 12 2

Kelantan 1.53 1 4 1 3 6 2 2 5 1

Melaka 0.73 3 11 4 4 8 5 1 2 1

Negeri Sembilan 0.96 2 7 2 2 4 2 2 5 2

Pahang 1.45 1 4 1 2 4 1 1 2 1

Perak 2.28 3 11 1 5 9 2 4 10 2

Terengganu 1.04 1 4 1 1 2 1 2 5 2

Pulau Pinang 1.49 3 11 2 7 13 5 2 5 1

Sabah 3 0 0 0 3 6 1 6 14 2

Sarawak 2.36 0 0 0 5 9 2 6 14 3

Selangor & W.P Kuala Lumpur 6.43 8 29 1 13 25 2 7 17 1

74 Table 2: Available Medical Devices in Ophthalmology and Optometry Specialties. Phaco- Population A scan B Scan emulsification Fundus Camera machine No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 118 100 4 64 100 2 76 100 3 40 100 1

Sector Public - 71 60 38 59 44 58 22 55 Private - 47 40 26 41 32 42 18 45

State Johor 3.17 10 8 3 4 6 1 8 11 3 3 8 1 Kedah & Perlis 2.11 10 8 5 5 8 2 6 8 3 4 10 2 Kelantan 1.53 5 4 3 2 3 1 3 4 2 1 2 1 Melaka 0.73 3 3 4 3 5 4 7 9 10 1 2 1 N. Sembilan 0.96 5 4 5 3 5 3 2 3 2 1 2 1 Pahang 1.45 7 6 5 3 5 2 3 4 2 1 2 1 Perak 2.28 7 6 3 4 6 2 5 7 2 1 2 0 Terengganu 1.04 2 2 2 2 3 2 2 3 2 1 2 1 Pulau Pinang 1.49 20 17 13 16 25 11 11 14 7 6 15 4 Sabah 3 9 8 3 3 5 1 3 4 1 2 5 1 Sarawak 2.36 9 8 3 2 3 1 2 3 1 4 10 2 Selangor & W.P 6.43 31 26 5 17 27 3 24 32 4 15 38 2 Kuala Lumpur

Indirect Anterior Segment Operating Population Slit Lamp Ophthalmoscope Camera Microscope No in million No % pmp No % pmp No % pmp No % pmp Malaysia 26.64 ------

Sector Public - 267 - 143 - 18 - 83 - Private - ND - ND - ND - ND -

State Johor 3.17 27 10 9 11 8 3 1 6 0 8 10 3 Kedah & Perlis 2.11 28 10 13 13 9 6 4 22 2 10 12 5 Kelantan 1.53 11 4 7 7 5 5 0 0 0 3 4 2 Melaka 0.73 15 6 21 5 3 7 0 0 0 2 2 3 N. Sembilan 0.96 10 4 10 5 3 5 0 0 0 4 5 4 Pahang 1.45 13 5 9 10 7 7 1 6 1 4 5 3 Perak 2.28 25 9 11 10 7 4 3 17 1 6 7 3 Terengganu 1.04 13 5 13 9 6 9 2 11 2 3 4 3 Pulau Pinang 1.49 20 7 13 8 6 5 1 6 1 6 7 4 Sabah 3 15 6 5 3 2 1 1 6 0 8 10 3 Sarawak 2.36 14 5 6 13 9 6 1 6 0 7 8 3 Selangor & W.P 6.43 76 28 12 49 34 8 4 22 1 22 27 3 Kuala Lumpur

75 Population Cryo Machine Vitrectomy Machine

No in million No % pmp No % pmp Malaysia 26.64 ------

Sector Public - 32 - 28 - Private - ND - ND -

State Johor 3.17 1 3 0 3 11 1 Kedah & Perlis 2.11 6 19 3 5 18 2 Kelantan 1.53 2 6 1 1 4 1 Melaka 0.73 0 0 0 1 4 1 Negeri Sembilan 0.96 2 6 2 1 4 1 Pahang 1.45 2 6 1 1 4 1 Perak 2.28 3 9 1 0 0 0 Terengganu 1.04 1 3 1 1 4 1 Pulau Pinang 1.49 1 3 1 1 4 1 Sabah 3 1 3 0 1 4 0 Sarawak 2.36 3 9 1 2 7 1 Selangor & W.P Kuala Lumpur 6.43 10 31 2 11 39 2

Ophthalmic Laser Systems

Population Nd. YAG Endolaser Nd. Argon Diode

No in million No % pmp No % pmp No % pmp No % pmp

Malaysia 26.64 46 100 2 19 100 1 58 100 2 26 100 1

Sector Public - 23 50 15 79 37 64 22 85 Private - 23 50 4 21 21 36 4 15

State Johor 3.17 3 7 1 0 0 0 5 9 2 3 11 1 Kedah & Perlis 2.11 4 8 2 4 21 2 4 7 2 3 11 1 Kelantan 1.53 0 0 0 1 5 1 3 5 2 2 8 1 Melaka 0.73 3 7 4 1 5 1 3 5 4 1 4 1 N. Sembilan 0.96 0 0 0 0 0 0 2 3 2 1 4 1 Pahang 1.45 2 4 1 0 0 0 2 3 1 3 12 2 Perak 2.28 3 7 1 1 5 0 4 7 2 2 8 1 Terengganu 1.04 1 2 1 1 5 1 1 1 1 0 0 0 Pulau Pinang 1.49 8 17 5 3 16 2 7 12 5 2 8 1 Sabah 3 4 9 1 1 5 0 5 9 2 1 4 0 Sarawak 2.36 2 4 0 1 5 0 4 7 2 1 4 0 Selangor & W.P 6.43 16 35 2 6 32 1 18 31 3 7 27 1 Kuala Lumpur

76 Population Excimer

No in million No % pmp

Malaysia 26.64 4 100 0

Sector

Public - 1 25

Private - 3 75

State

Johor 3.17 1 25 0 Kedah & Perlis 2.11 0 0 0 Kelantan 1.53 0 0 0 Melaka 0.73 0 0 0 Negeri Sembilan 0.96 0 0 0 Pahang 1.45 0 0 0 Perak 2.28 0 0 0 Terengganu 1.04 0 0 0 Pulau Pinang 1.49 1 25 1 Sabah 3 1 25 0 Sarawak 2.36 0 0 0 Selangor & W.P Kuala Lumpur 6.43 1 25 0

CHAPTER 19 GAPS IN MEDICAL TECHNOLOGY IN MALAYSIA

Table 19.1 Imaging & Diagnostic Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance

1. High Resolution Computed Availability: Marketed. Tomography (CT) system for Function: Diagnostic. Neuroradiology and Cardiac Existing Alternative Options: MRI, angiography work. Clinical Effectiveness: Capable to reduce up to 25% of interventional neuroangiography, excellent perfusion CT angiography. Life-Saving Outcomes: Improves selection criteria 1 for interventional neuroangiography with improved outcomes. Health-Cost Implications: Will increase health cost but maybe offset by more selective neuro –angiograms. Safety Issues: Increase radiation dose. Prioritization: Required in the next 5 years. 2. Cone-beam Breast Computed Availability: Experimental Tomography (CBBCT) Function: Diagnostic. Existing Alternative Options: Mammography, ultrasonography. Clinical Effectiveness: Higher resolution hence more sensitive. Radiation dose comparable to 2-view mammography, imaging post op breast with deformity. Life-Saving Outcomes: Improves image quality with 3-D 2 images, hence improving cancer detection rates. Health-Cost Implications: Increase true put, duration of scan less than 1 minute. Safety Issues: - Prioritization: To be introduced within the next 5 years.

3. Magnetic resonance Availability: Marketed spectroscopy Function: Diagnostic Existing Alternative Options: - Clinical Effectiveness: - Life-Saving Outcomes: Faster and more accurate diagnosis. 3 Health-Cost Implications: Increased access to MRI and increased unit cost compared to alternative. Safety Issues: Quick and less radiation. Prioritization: To be introduced within the next 5 years.

79 Table 19. 2 Oncology Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance

1. Helical TomoTherapy machine. Availability: Marketed. Function: Therapeutic. Existing Alternative Options: Linear accelerator. Clinical Effectiveness: Less morbidity associated with treatment, better dose escalation. Good to consider technological improvement in terms of reduction radiation exposure. Life-Saving Outcomes: Better with more precise 1 treatment. Health-Cost Implications: Very expensive machine, treatment cost per patient is very much higher Safety Issues: Increased risk if used by inexperienced doctors Prioritization: To be introduced within the next 5 years.

80 Table 19. 3 Anaesthesiology and Intensive Care Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance

1. Whole-body cooling system. Availability: Marketed. Function: Assistive. Existing Alternative Options: Water blankets/ mattresses. Clinical Effectiveness: Avoids immediate and long- term morbidity associated with hypothermia. Ease of use and easier monitoring. Life-Saving Outcomes: Reduces mortality and morbidity 1 associated with newborn hypothermia. Health-Cost Implications: Less costly than selective head cooling system. Safety Issues: Prioritization: To be reintroduced within the next 2 years 2. Amplitude-integrated Availability: Marketed Electroencephalography (aEEG) Function: Diagnostic and assistive Existing Alternative Options: Clinical assessment. The conventional full 12-lead EEG for the same indication is impractical. Clinical Effectiveness: Detection of seizures, level of consciousness, state of sleep or sedation of baby. Able to provide trending over a period of time especially for 2 newborns with moderate to severe birth asphyxia. Life-Saving Outcomes: Health-Cost Implications: Safety Issues: Need to interpret aEEG correctly. Prioritization: To be introduced within the next 2 years.

3. Infant Transport Mattress Availability: Marketed. Function: Assistive. Existing Alternative Options: None. Clinical Effectiveness: This chemical mattress is used together with the overhead radiant warmer during the resuscitation of extremely low birth weight babies and transport to the neonatal intensive care (NICU) following the resuscitation. This would avoid the complications of 3 hypothermia. Life-Saving Outcomes: Reduces mortality. Health-Cost Implications: - Safety Issues: May occasionally overheat the baby. Prioritization: To be introduced within the next 5 years.

81 4. Olympic Cool Cap System for Availability: Marketed. Selective Head Cooling Function: Therapeutic. Existing Alternative Options: Supportive therapy, no definitive therapy available. Clinical Effectiveness: Has been shown to reduce mortality and neuro-developmental abnormalities associated with birth asphyxia. Induced hypothermia needs to be carefully controlled and Cool Cap is often used with amplitude EEG monitoring. Life-Saving Outcomes: Reduces mortality. Health-Cost Implications: 1. Expensive system may not be easily available. 2. Total cost with EEG is about RM200,000. However, if effective in reducing disabilities, it may save cost of rehabilitation for both parents and the Ministry of Health. Safety Issues: 4 1. FDA approved. 2. Complications associated with hypothermia 3. Sinus bradycardia, arrhythmias, hypotension, coagulopathy and increased risk of infections 4. Does technology reduce mortality but increase major disability in survivors? Prioritization: To be introduced within the next 5 years.

Additional comments: 1. Although theoretically, the whole body cooling system is more effective, there are no studies comparing these two modalities and results of 3 large multicentre randomized clinical trials on the safety and effectiveness of the whole body cooling systems are still pending.

82 Table 19.4 Orthopaedic and Traumatology Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance

1. ISO-C C-ARM Imaging System. Availability: Marketed. Function: Assistive. Existing Alternative Options: - Clinical Effectiveness: Very good reduced morbidity. 1 Life-Saving Outcomes: Very good. Health-Cost Implications: Cost effective. Safety Issues: X-ray precautions are required. Prioritization: Urgent introduction required. 2. Radiolucent operating tables. Availability: Marketed. Function: Assistive. Existing Alternative Options: - Clinical Effectiveness: Very good reduced morbidity 2 Life-Saving Outcomes: Very good Health-Cost Implications: Cost effective. Safety Issues: - Prioritization: Urgent introduction required. 3. Navigation systems for trauma Availability: Marketed surgery. Function: Assistive Existing Alternative Options: - Clinical Effectiveness: Very good reduced morbidity. Life-Saving Outcomes: Very good. 3 Health-Cost Implications: Cost effective Safety Issues: Nil Prioritization: Urgent introduction required.

4. SomatoSensory Evoked Availability: Marketed Potential (SSEP) device for Function: Assistive intraoperative monitoring during Existing Alternative Options: - cervical spine surgery. Clinical Effectiveness: Very good reduced morbidity 4 (Used in combination with Life-Saving Outcomes: Very good Motor Evoked Potential (MEP)) Health-Cost Implications: Cost effective. Safety Issues: - Prioritization: Urgent introduction required. 5 Bone morphogenic proteins. Availability: Marketed Function: Therapeutic. Existing Alternative Options: Other modalities such as Autologous Bone Graft and Synthetic. Bone Graft. 5 Clinical Effectiveness: For faster fracture union and very good reduced morbidity. Life-Saving Outcomes: Very good. Health-Cost Implications: Cost effective. Safety Issues: - Prioritization: see other existing technologies currently being used.

83 Table 19.5 Physiotherapy and Occupational Therapy Technologies.

Gaps in medical Technology Rank of # Expert Opinion in Malaysia Importance

1. Real Time Ultrasound Imaging Availability: Marketed (Physiotherapy) Function: Diagnostic and therapeutic Existing Alternative Option: Nil Clinical Effectiveness: Enables identification of inflammation, tears and ruptures, lesions, fluid collections and soft tissues masses so that intervention can be specific to the problems. Muscle actions can be viewed and used to assist patients to work effectively. Life – saving outcomes: Improves quality of patients’ life 1 Health – Cost Implication: RM60,000,00. It is cost effective in the long term because it can be applied and used in measurement and reeducation of muscles in musculoskeletal and uro-gynaecological cases. Safety Issues: minimal effects Prioritization: to introduced in the next 2 years.

2. VO2max Indirect Spirometry with Availability: Marketed

gas analysis - O2 consumption and Function: Diagnostic purpose

CO2 production Existing Alternative Option: Portable oxymeter. Clinical Effectiveness: To determine lung function, gas exchange & secretion retention in the lung. Life-Saving outcomes: Improves quality of life 1 Health-Cost Implication: RM 50,000.00 (Moderate cost) Safety Issues: Minimal effects Prioritization: High

3. Acapella Counterweighted plug Availability: Marketed. and accessories Function: Therapeutic and Assistive. Existing Alternative Option: Flutter. Clinical Effectiveness: Effective in secretion clearance and improves lung ventilation. Life-Saving outcomes: Small device easy to use, can be administered by patient with minimal supervision 1 from clinicians. Health-Cost Implication: Low cost below RM 5000.00 Safety Issues: Minimal effects. Prioritization: Urgent introduction required

4. E-link Upper and Lower Availability: Marketed Extremity evaluation and exercise Function: Therapeutic / Preventive / Diagnostic system Existing Alternative Option: Manual techniques and varieties of evaluation tools e.g goniometer, measuring tape, sensory evaluation tools etc. Clinical Effectiveness: Able to accurately and objectively assesses joints and motor performance and to plan appropriate therapeutic interventions according to patients’ needs. 2 Life – Saving outcomes: Improve patients’ quality of life Health – Cost Implication: RM200,000.00. Reduce cost of hospitalization as precise plan of treatment can be undertaken according to the patients’ impairment. Safety Issues: Minimal effects Prioritization: To be introduced within next 5 years.

84 5. High Frequency Radial Availability: Marketed. Shockwave Therapy Function: Therapeutic. Existing Alternative Option: Ultrasound therapy and laser therapy. Clinical Effectiveness: Shown to be effective in pain management of musculoskeletal conditions based on the mechanical application of vibrating pulses to tensed, shortened or overstretched muscles and tendons by means of the shock frequencies. Life-Saving outcomes: Improves quality of patients’ 3 life. Health-Cost Implication: RM70,000,00. Effective treatment outcome is effective and duration of treatment is shortened compared to conventional therapeutic devices. Safety Issues: Minimal effects Prioritization: to be introduced in next 5 years.

6. Muscle tester with Mega EMG Availability: Marketed system Function: Diagnostic Existing Alternative Option: Nil Clinical Effectiveness: Measurement of muscles performance and biomechanic analysis and its’ data can be processed for research purposes. Easy application in the field, treatment room or in biomechanics laboratory 4 Life-Saving outcomes: Evidence based measurement Health-Cost Implication: Low cost. (Below RM100, 000) Safety Issues: Relatively very safe Prioritization: To introduced in the next 2 years.

7. Pediatric Lokomat, Intensive Availability: Marketed Locomotion Therapy for children Function: Therapeutic and Assistive Existing Alternative Option: Manually assisted ambulation. Clinical Effectiveness: Effective intervention for improving walking function in children with disabilities. Life-Saving Outcomes: Reduced the manual labour 5 required for ambulation training. More efficient in achieving treatment goals. Health-Cost Implication: High cost more than RM100, 000.00 Safety Issues: Minimal effects Prioritization: To introduced in next 5 years.

8. Gait analyzer Availability: Marketed. Function: Assessment of impairment. Existing Alternative Option: digital video camera. Clinical Effectiveness: Shown to be accurate in analyzing gait impairment enable the therapist to make appropriate physiotherapy impression in order to plan physiotherapy management. Life-Saving Outcomes: Improve patients’ quality of 6 life. Health-Cost Implication: RM 500,00.00. Reduce cost of hospitalization as precise plan of treatment can be undertaken according to the patients’ impairments. Safety Issues: minimal effects Prioritization: to be introduced within next 5 years

85 9. Balance system – static and Availability: Marketed. dynamic balance testing and Function: Therapeutic and diagnostic. training with five interactive Existing Alternative Option: Balance foam for balance training modes (Biodex) training. Clinical Effectiveness: Effective in balance training for patients with vestibular impairment or neurological conditions especially in geriatrics. Provides fast and accurate fall risk assessment plus closed chain, weight bearing assessment and training for lower extremity 7 training. Life-Saving Outcomes: Improves quality of life. Health-Cost Implication: Moderate cost RM100, 000.00. Safety Issues: Minimal effects Prioritization: To be introduced in the next 5 years.

Note: 1. The Acapella and Vo2 max indirect spirometry with gas analysis are urgently required for effective chest care and respiratory rehabilitation. 2. Real Time Ultrasound Imaging (Physiotherapy) is our top priority in view of physiotherapists’ expanded role in the care of musculoskeletal problems and urogynaecology cases. With this machine, we are able to provide more effective treatment by active participation from patients through viewing of images of muscle work on the screen which is in line with our evidence-based practice. 3. The DBC is the least priority among others because of its high costs and maintenance, and also the space required to place the machine. Besides this, there is a requirement for staff to be well and intensively trained before they are confident enough to handle the machine. Though it is a machine with high technology but it only benefits a small client group such as the industrial workers for the purposes of compensation.

86 Table 19.6 Obstetrics and Gynaecology Technologies.

Gaps in Medical Technology in Rank of # Expert Opinion Malaysia Importance

1. Polar probe. Availability: Marketed Function: Diagnostic (Screening for cervical cancer) Existing Alternative Options: PAP Smear or spectrometry. Clinical Effectiveness: Can be used on its own or as an additional test for screening. Studies have shown that use of polar probe increases overall detection and reduces the false negative rate by pap smear. Many previous trials conducted with sensitivity and 1 specificity of 98 and 91% respectively. Life-Saving Outcomes: Reduces morbidity and mortality associated with cervical cancer. Health-Cost Implications: This system offer faster, simpler and cost effective standardized diagnosis. Safety Issues: - Prioritization: Required in the next 5 yrs. 2. Cryoprobe. Availability: Marketed. Function: Therapeutic. Existing Alternative Options: Conventional treatment. Clinical Effectiveness: Enables cervical cryosurgery to be conducted. The equipment is cheap, easy to maintain and has a short learning curve. Life-Saving Outcomes: Treatment failure is observed in about 5-10% of women. Health-Cost Implications: - Safety Issues: Limitations include: 1. Cryosurgery is not usually feasible for large abnormal areas. 2. The procedure removes abnormal, but 2 noncancerous, tissue by freezing it. 3. As a result of the procedure, some patients experience cramping, watery discharges, temporary changes in menstrual periods and increased risk of transmissibility of HIV infection. However, cryosurgical treatment is very well tolerated by patient as there is little to no discomfort in most cases, negating the requirement of anaesthesia. It is considered safe with minimal complication and less than 1% develops cervical incompetence and no effect on fertility. Prioritization: To be introduced within the next 5 years.

87 3. AmniSure Placental Alpha Availability: Marketed Microglobulin-1 Rapid Function: Diagnostic Immunoassay Existing Alternative Options: - All current methods used are deficient in diagnosing Premature Rupture of Membrane (PROM). Clinical Effectiveness: A rapid bedside strip test that can detect rupture of foetal membranes with a high degree of predictive accuracy. Testing for PAMG-1 increases the sensitivity of detecting small quantities 3 of amniotic fluid in the vagina. Life-Saving Outcomes: Reduces both maternal and foetal morbidity and mortality related to premature ruptures of membranes. Health-Cost Implications: As above Safety Issues: - Prioritization: To be introduced within the next 5 years.

4. Robotics surgery equipment Availability: Marketed Function: Diagnostic Existing Alternative Options: Conventional medical treatment / surgery including laparoscopic surgery. Clinical Effectiveness: It utilizes high definition 3- dimension vision and intuitive motion and therefore, gives greater ability to dissect compromised anatomy and tissue places as well as ability to operate on large pathology and obese patients. There is superior visualization of tissue planes, superior ability to reconstruct defect and more precise and potentially 4 safer dissection of pelvic pathology. Life-Saving Outcomes: As above. Health-Cost Implications: Less pain with fewer complications and shorter hospital stays. Therefore, patients may have faster recoveries. Safety Issues: - Prioritization: Robotics is a surgical avenue that has to be assessed for its potential in future gynaecological surgery.

88 Table 19.7 Neurology Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance

1. Stroke unit facility. Availability: - Function: Therapeutic. Existing Alternative Options: - Clinical Effectiveness: Various clinical papers on effectiveness of having a stroke unit. 1 Life-Saving Outcomes: Improve outcome morbidity. Health-Cost Implications: - Safety Issues: - Prioritization: Urgent introduction required.

2. 256-slice computed Availability: Marketed tomography (CT) system. Function: Diagnostic Existing Alternative Options: MRI, angiography. Clinical Effectiveness: Capable to reduce up to 25% interventional neuroangiographies, excellent perfusion CT angiography. Life-Saving Outcomes: Improve selection criteria for interventional neuro-angiographies with improved 2 outcomes. Health-Cost Implications: Will increase health cost but maybe offset by more selective neuroangiograms. Safety Issues: Increase radiation dose. Prioritization: Urgent introduction required (should be come along with stroke unit facility)

3. Computer software to register Availability: Marketed all stroke patients. Function: Assistive Existing Alternative Options: - Clinical Effectiveness: Facilitate clinical audit/ research studies. 3 Life-Saving Outcomes: - Health-Cost Implications: - Safety Issues: - Prioritization: Required urgently in public hospitals.

4. Serology testing for Availability: Marketed. paraneoplastic panel/ Function: Diagnostic. antibodies Existing Alternative Options: serology conducted in Australia. Clinical Effectiveness: Detect and confirm paraneoplastic syndromes based on presence of paraneoplastic antibodies. Life-Saving Outcomes: Early treatment with 4 immunomodulating therapies. Health-Cost Implications: Improve quality of life, reduce mortality. Safety Issues: Prioritization: Urgent introduction required.

5. MERCI Clot Retriever. Availability: Marketed Function: Therapeutic. Existing Alternative Options: Clinical Effectiveness: MERCI trial published. Life-Saving Outcomes: Improves morbidity outcomes. 4 Health-Cost Implications:- Safety Issues:- Prioritization: Required in the next 5 years.

89 6. VNS Therapy device. Availability: Marketed/ experimental. Function: Therapeutic. Existing Alternative Options: - Clinical Effectiveness: Used for treatment-resistant epilepsy and in treatment-resistant depression, VNS Therapy may provide limited relief as an adjunctive treatment for long-term depression patients. Life-Saving Outcomes: Reduces the number of suicides 6 in the long term. Health-Cost Implications: - Safety Issues: No new evidence for safety and effectiveness. Prioritization: -

Table 19.8 Psychiatry and Mental Health Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance

1. Transcranial Magnetic Availability: Experimental. Stimulation (TMS) device. Function: Therapeutic. Existing Alternative Options: Antidepressant Therapy, Psychotherapeutic Interventions & Electroconvulsive Therapy Clinical Effectiveness: Uncertain. Life-Saving Outcomes: No. Health-Cost Implications: Cost of purchasing To be machines considered when Safety Issues: Not reported. more evidence Prioritization: Required within the next 5 years. available Comments: It is currently considered an alternative when everything else fails, or those who are not keen to undergo ECT. In USA, it is not approved yet by FDA and its use is for research purposes.

90 Table 19. 9 Cardiology and Cardiothoracic Surgery Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance

1. Emerging Biomarkers Availability: Experimental Function: Preventive and diagnostic. Existing Alternative Options: - Clinical Effectiveness: Research purposes. (need for local community data) Life-Saving Outcomes: Potentially life-saving. 1 Health-Cost Implications: Cost will be higher at the initial stages. Safety Issues: - Prioritization: Urgent introduction required. 2. Hand held Echocardiography Availability: Marketed unit (community based use). Function: Preventive and Diagnostic. Existing Alternative Options: Currently available hospital based. Clinical Effectiveness: Reasonable but technologies continue to improve. Life-Saving Outcomes: Enables earlier referrals well as avoids unnecessary referrals. 2 Health-Cost Implications: Earlier diagnosis of heart failure and valvular heart disease. Safety Issues: - Prioritization: Community-based use should be introduced urgently or at least within the next five years.

3. Percutaneous valvular Availability: Marketed/ Experimental interventions. Function: Therapeutic. Existing Alternative Options: - Clinical Effectiveness: There has been continuous improvement in this technology and will definitely replace surgery. Life-Saving Outcomes: Life–saving. 3 Health-Cost Implications: Technology will progressively be cheaper compared to surgery. Safety Issues: - Prioritization: Technology should be introduced urgently or at least within the next five years. 4. Percutaneous Left Ventricular Availability: Marketed Assist device. Function: Assistive Existing Alternative Options: Intra-aortic balloon pump. Clinical Effectiveness: Bridge to transplant. 4 Life-Saving Outcomes: Prolongs life. Health-Cost Implications: $200,000 initial cost Safety Issues: Unsuitable for long term use Prioritization: Urgent introduction required. 5. Stereotactic Intervention Availability: Marketed/ Experimental Function: Diagnostic and therapeutic. Existing Alternative Options: - Clinical Effectiveness: Allows remote control without the need for radiation. Life-Saving Outcomes: Technology is replacing the 5 current percutaneous techniques. Health-Cost Implications: Need to be looked into. Safety Issues: - Prioritization: To be introduced within the next five years. To be considered

91 Table 19. 10 Respiratory Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance 1. Positive Expiratory Pressure Availability: Marketed and available Devices (PAP) with mask/ Function: Therapeutic. mouthpiece Existing Alternative Options: 1) Autogenic drainage techniques. 2) Active cycles of breathing techniques. Clinical Effectiveness: Provide constant backpressure to airways during expiration to assist 1 / improve secretion clearance by building up gas behind mucus via collateral ventilation. Shown to be effective in secretion clearance. Life-Saving Outcomes: - Health-Cost Implications: Low cost. Safety Issues: - Prioritization: Urgent introduction required. 2. Smartinhaler. Availability: Experimental. Not available Function: Therapeutic. Existing Alternative Options: - Clinical Effectiveness: A digital asthma management device that incorporates a microcomputer for automated collection of data on medication usage, lung function and dose reminder alarm. The data are uploaded online by the patient, 2 and is accessible to their clinician. Life-Saving Outcomes: Reduces morbidity, improves quality of life of patient and potential decrease in use of emergency care. Health-Cost Implications: Increased cost compared to alternative treatment option. The increased cost in capital investment may be offset by the potential reduction in emergency care due to improved patient management. Safety Issues: Diarrhoea. Prioritization: Urgent introduction needed 3. Serum Procalcitonin (PCT) test kit. Availability: Marketed. Function: Diagnostic and assistive. Existing Alternative Options: Blood cultures (lower sensitivity and specificity especially in nosocomial infection). Clinical Effectiveness: Effective in diagnosing and identifying nosocomial pneumonia accurately. It is 3 useful as a marker of severe sepsis. Life-Saving Outcomes: Patients have good outcome. It is critical in the intensive care setting. Health-Cost Implications: It is very cost- effective as patients with SIRS and sepsis can be differentiated. It avoids unnecessary treatment. Safety Issues: - Prioritization: Urgent introduction required.

92 4. Pneumococcal Antigen test Availability: Marketed. Function: Diagnostic. Existing Alternative Options: Culture and sensitivity tests. Organism identification is difficult to obtain due to poor yield via sputum or blood. In addition, they are lengthy and less reliable. Clinical Effectiveness: Provides quick results to identify definite organism (Streptococcus Pneumonia) Life-Saving Outcomes: Patients have better 4 outcome as appropriate antibiotic choice will be given to patients. Health-Cost Implications: This 15- minute urine dipstick test is able to diagnose Pneumococcal Pneumonia and cuts down unnecessary invasive investigations. Safety Issues: Prioritization: Urgent introduction required.

5. Anti-viral Resistance Study for Availability: Marketed. Influenza. Function: Preventive and Therapeutic. Existing Alternative Options: None. Clinical Effectiveness: Life-Saving Outcomes: 5 Health-Cost Implications: Assist MOH in stockpiling of antiviral drug against influenza as part of National Influenza Pandemic Preparedness Plan Safety Issues: Not applicable. Prioritization: Urgent introduction required.

6. Hand held (portable) “Exhaled Availability: Marketed. Not in use nitric oxide measurement” Function: Preventive and diagnostic. devices - more user friendly. Existing Alternative Options: Exhaled nitric oxide measurement device. Clinical Effectiveness: For early management intervention and follow up of asthmatic patients Life-Saving Outcomes: 6 Health-Cost Implications: It is very cost effective and should be made available in all centre of excellence for respiratory - for both, patient management and research purposes. Safety Issues: - Prioritization: Required within the next 2 years.

7. Automated lung sound analysis Availability: Educational Function: Diagnostic. Existing Alternative Options: Radiological 7 examination Clinical Effectiveness: - Life-Saving Outcomes: - Health-Cost Implications: - Safety Issue : - Prioritization: Required within the next 5 years

93 8. Obstructive Sleep Apnea (OSA) Availability: Marketed/ experimental and not detector with alertness index to available

monitor SpO2 level. Function: Preventive and Diagnostic. Existing Alternative Options: Overnight Polysomnography in Sleep Lab/ Home 8 (ambulatory) PSG and CPAP machine. Clinical Effectiveness: Life-Saving Outcomes: Health-Cost Implications: Safety Issues: Prototype may not be user friendly and experimental. Prioritization: Introduction required within next 5 years.

9. SLE 5000 ventilator Availability: Marketed. Function: Therapeutic. Existing Alternative Options: Bear cup ventilator. Clinical Effectiveness: Improves patient outcome. 9 Life-Saving Outcomes: Improve the quality of life. Health-Cost Implications: Reduce hospital stay Safety Issues: Prioritization Required within the next 5 years.

94 Table 19.11 Urology Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance

1. Hexaminolevulinate fluorescence Availability: Marketed blue-light cystoscopy Function: Diagnostic Existing Alternative Options: Cystoscopy and urine cytology. Clinical Effectiveness: Improves detection of precursor lesions, dysplasia, and CIS 1 Life-Saving Outcomes: earlier detection with earlier treatment may translate to better outcomes Health-Cost Implications: - Safety Issues: - Prioritization: High

2. Brachytherapy Availability: Marketed Function: Therapeutic Existing Alternative Option: Surgery or Radiotherapy Clinical Effectiveness: Proven for low grade low stage tumours. Life-Saving Outcomes: Reduces morbidity and 2 mortality of patients. Health-Cost Implications: Cost of radioactive seeds Safety Issues: Precaution needed to handle radioactive material. Prioritization: High.

Table 19.12 Dermatology Technologies.

Gap in medical technology Rank of # Expert opinion in Malaysia Importance 1. Excimer Laser Availability: Marketed. for Treatment of Psoriasis and Function: Therapeutic. Vitiligo Existing Alternative Option: Regional phototherapy unit. Clinical Effectiveness: Localised resistant psoriasis and vitiligo. 1 Life-Saving outcome: Nil of note. Health-Cost Implication: Costly. Safety Issue: Safe. Prioritization: Within 5 years.

2. Compliment of Laser System Availability: Marketed for Cosmetic Dermatology Function: Therapeutic Existing Alternative Option: Laser’s with varied dermatological specific function. Clinical Effectiveness: Pigmentary, vascular and ablative tumour/scar related skin problem 2 Life-Saving outcome: Nil of note Health-Cost Implication: Costly Safety issue: safe Prioritization: Within 5 years

95 3. Photodynamic therapy (PDT). Availability: Marketed. Function: Therapeutic. Existing Alternative Option: Nil. Clinical Effectiveness: Useful for solar keratosis, Bowen’s disease and Squamous Cell Carcinoma. 3 Life-Saving outcome: Nil of note. Health-Cost Implication: Costly. Safety Issue: safe. Prioritization: Within 5 years. 4. Extracorporeal Photophoresis Availability: Marketed. for Sezary Syndrome and Function: Therapeutic. Mycosis Fungoides. Existing Alternative Option: Electron beam or chemotherapy. Clinical Effectiveness: Sezary syndrome or Mycosis Fungoides requiring electron beam or chemotherapy. 4 Life-Saving outcome: Prolong survival Health-Cost Implication: Costly Safety Issue: Potential procedure related complications Prioritization: Within 5 years

96 Table 19.13 Otorhinolaryngology and Audiology Technologies.

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance 1. Tinnitus retraining therapy Availability: Marketed. devices. Function: Therapeutic. Existing Alternative Options: Ear level devices (tinnitus maskers, hearing aids). Clinical Effectiveness: - Life-Saving Outcomes: Nil 1 Health-Cost Implication: - Safety Issues: - Prioritization: Urgent introduction required.

2. Middle ear implant. Availability: Marketed. Function: Assistive. Existing Alternative Options: Conventional hearing aid. Clinical Effectiveness: Improves quality of life. Life-Saving Outcomes: Nil. Health-Cost Implications: Reduced cost of 2 maintenance and disposable battery compared to conventional hearing aid. Safety Issues: Must be conducted by credentialed surgeon. Prioritization: Required in the next 2/3 years

3. Auditory brainstem implant. Availability: Marketed. Function: Advance Assistive. Existing Alternative Options: Nil Clinical Effectiveness: For selected/suitable patients. Life-Saving Outcomes: Nil of note. 3 Health-Cost Implications: Very costly. Safety Issues: Possible migration Prioritization: Required in the next 5 years.

97 Table 19.14 Ophthalmology & Optometry Technologies

Gaps in Medical Technology Rank of # Expert Opinion in Malaysia Importance 1. Nd:YAG laser for Selective Availability: Marketed Laser Trabeculoplasty. Function: Therapeutic Existing Alternative Options: Argon Laser trabeculoplasty. Clinical Effectiveness: The technique can successfully lower intraocular pressure in about 80% of cases and treatment is painless or nearly painless for most patients. 1 Life-Saving Outcomes: - Health-Cost Implications: Can be performed on an outpatient basis. Safety Issues: It causes no burning or scarring of the trabecular meshwork and is repeatable with minimal risk. Prioritization: High

98 99 Malaysian Statistics On MEDICAL DEVICES 2007

Ariza Zakaria Faridah Aryani Md. Yusof Lim T.O.