Research Centre for Safety and Quality in Health (SQH)

ศูนย์วิจัยเพื่อความปลอดภัยและคุณภาพด้านสุขภาพ

About SQH

History
          SQH was established in 2016 to provide research for safety and quality in health. Quality and safety of people was important issue which make impact to Thailand and international medical community. The centre of researchers and healthcare professionals including research, education, training and academic services in health, epidemiology, biology, herbal and natural products and consumer protection. In order to find information and knowledge on important issues needed in the development of public safety

Mission statement
          The Centre aims to maintain the health of all Thais through collecting data and recommending the effective and safe drug use in medical practice.


External collaborations

Thai Networks

     1. Health Product Vigilance Center, Ministry of public health, Thailand
     2. Social Research Institute, Chulalongkorn University
     3. Hospitals in Lower North of Thailand
     4. Department of traditional and alternative medicine, and Thai FDA Ministry of Public Health
     5. Sirindhorn College of Public Health, Phitsanulok

International networks

     1. WHO Uppsala Monitoring Centre, Sweden
     2. LAREB Pharmacovigilance Centre, WHO Collaborating Centre for Pharmacovigilance in Education and Patient Reporting, Netherlands
     3. Sheppard Pratt Health System, in partnership with University of Maryland, US
     4. School of Pharmacy, University Collage of London (UCL), UK
     5. School of Pharmacy, The University of Manchester, UK


Education

Healthcare landscape in Thailand

     Thailand, like many other emerging economies, has seen a revolution in health care beginning in the 1970s when treatment needs were dominated by infectious diseases, malnutrition and physical injury. Now demands on medicine has transitioned to those caused by lifestyle changes. All members of the Thai populous have seen a vast improvement in health-care through universal coverage and a structured layering of health-care professionals from doctors, practicing in a hierarchy of hospitals, nurses and assistants down to community workers insuring unfettered access to health care in the most remote areas. This is supplemented by the private section having access to the latest drugs and techniques which are affordable by the middle classes and renowned in the east Asian region for affordable quality treatment.

Pharmacy practice

The country facilitates studies in all aspects of use, effectiveness and safety of pharmaceuticals owing to its national universal health system and forward-looking ministerial departments. These attributes enabled Thailand to become a leader among emerging economies in pharmacy practice (pharmacovigilance, medication adherence, policy, etc.), a role to which the centre has contributed. These surveys have led to a better understanding of health and pharmaceutical care and its challenges in an advancing economy. Past and current areas of endeavor are:
Medication-related problems
(i) Adherence to medication: This is a major challenge in chronic diseases where many treatments are life-long and aim to prevent further deterioration in health (eg diabetes and its dependent pathologies) or reduce risk factors for major debilitating events eg (vascular disease and obesity). These lifestyle diseases may have no symptoms thus patients feel no improvement that motivate continued drug administration. Achieved: We have shown that polypharmacy is an important risk and pharmacists are positioned to monitor and encourage patients living independently to better adhere to treatments.
(ii) Medication errors: Chronic disease, polypharmacy and overstretched health care professionals are risks for medication errors. Missing or incorrect medication both have adverse outcomes requiring additional resources including hospitalisation and burden on carers and their patients. This is a global problem but how such errors arise depends on local differences in the medication delivery method to patient. Errors can occur at any stage of the medication trail between prescription and administration to the patient. Achieved: In district hospitals, we have identified pharmacists as best intercept and correcting such errors after the prescriber, because they are best able to spot discrepancies between the medication use and the patient’s circumstances.
Medication safety
(iii) Pharmacovigilance (PV): An important part of pharmacy practice is surveillance of prescription drugs for adverse events experiences reported by consumers. This plays an important part in maintain drug safety particularly for rare or delayed occurrences not observed in clinical trials. We have shown that the application of PV to herbal medicines (HMs) is patchy and of limited effectiveness. Worse still, HMs undergo little safety testing unlike allopathic medicines. We concluded that an easily accessible web based reporting system is needed to consumers and health professionals alike is urgently needed to fulfil this need. Also, it should be publicly accessible to query codified summary data about side effects of particular medicines.
Medication uses in vulnerable populations
(iv) Chronic pain in community elderly: Chronic pain is one of the most challenging health-care conditions to treat yet causes most misery. We have completed a joint survey with a group in Baltimore, USA on patients aged >50 yr suffering from chronic pain compared to those in Thailand. While the cohorts were different: more USA patients suffered from chronic disease while musculoskeletal were common in Thais arising from labouring occupations. Most striking was that none of the 1500 participants questionnaired were prescribed any opioid, mostly NSAIDs only, which accords with the Thai governments concern about addiction and misuse of opioids. In spite of non-use of opioids, most Thais were able to continue their independent living in spite of their disabilities. This appears to be a reflection of greater community and family interaction seen in the semi-urban environment where our cohort lived and greater sense of ordained predetermination (Budism). These observations have important implications for pain management in many western countries where opioid overprescribing is a major health scandal.
(v) Drug related problems in female prisoners in a female women correctional institution: A cross-sectional population study using a medication record review This study aimed to examine the prevalence rates of medication-related problems (MRPs) at a women’s correctional institution. Medical records were retrospectively reviewed to identify MRPs according to the guidelines of Pharmaceutical Care Network Europe (Classification V 6.2). MRPs arose from sub-optimal effects of drug treatment, an adverse event likely due drug-drug interactions, unnecessary drug treatment and (4.) laboratory test or medication dose not recorded. Most MRPs caused by inappropriate drug and dose selection which were too low. MRPs in a women’s correctional institution was substantial, especially in the drug ordering system, past medical history record, drug ordering and the limited amount of healthcare providers. This led to unnecessary drug treatment, duplicate and inappropriate drug use. The effective medication system including drug ordering system, adequate details in patient medical records and availability of medication experts should reduce MRPs women’s correctional institutions.
Medication safety
(iii) Pharmacovigilance (PV): An important part of pharmacy practice is surveillance of prescription drugs for adverse events experiences reported by consumers. This plays an important part in maintain drug safety particularly for rare or delayed occurrences not observed in clinical trials. We have shown that the application of PV to herbal medicines (HMs) is patchy and of limited effectiveness. Worse still, HMs undergo little safety testing unlike allopathic medicines. We concluded that an easily accessible web based reporting system is needed to consumers and health professionals alike is urgently needed to fulfil this need. Also, it should be publicly accessible to query codified summary data about side effects of particular medicines.

Efficacy and safety of herbal medicines

     Thailand has a rich history of traditional medicine and healers prescribing herbal preparations which is still practiced today. Like traditional Chinese and Ayurveda medicine, these healers apply holistic medicine as written in abundant ancient scripts describing the formulations, the conditions for which they are prescribed and adverse reactions. The Thai government is promoting their use and commercial exploitation and aims to incorporate traditional medicine into the national health-care system. Nevertheless, many clinicians who ultimately carry responsibility for their patents are skeptical about their efficacy and safety.
     Systematic review of studies on Thai traditional medicines: Herbal research in Thailand has focused on several traditional medicines and we have conducted systematic reviews including on Pueraria mirifica, Centilla asiatica as cosmetics , Ya-Hom, mitragynine, Bacopa monneria, ..etc. All studies suffered various degrees of weaknesses in protocol design, conduct, and analyses as judged Cochrane risk of bias, unclear composition of the medicine, and lacking safety information. Numerous Cochrane reviews on global herbal medicines show trials on herbal medicines reach similar conclusions and not confined to products we reviewed. Thus is became apparent that classical clinical trial protocols are inefficient ways of answering key questions about herbals as medicines. Furthermore, the government Department of Traditional Medicine voiced disquiet about the high cost of clinical trials. Yet their intention is to promote Thai traditional medicines as a major export earner.
     We have obtained major funding for a study on traditional and herbal medicines in Thailand that includes creating an internet resource for users of herbal medicines. This project comprises several stages:
      (i) Surveying the needs and expectations of consumers: Opinions and experiences of users, community leaders, and health workers in rural eastern Thailand were sought during 2018-19. Information learned from this cohort was that: (a) they recognise the safety issues of herbals that can be serious, (b) acceptable side effects are used as guide to their function, (c) herbal medicines are usually sourced locally, are unbranded, unlabelled crude preparations from local markets or door-to-door sales, but not expensive, standardised, blister packaged, nor branded, (d) the information about HMs they needed most was dosing information. Their view about safety seems different to the western perception that herbals, being natural, are safe. A video in which consumers voiced their opinions about herbal medicines is founded here https://www.youtube.com/watch?v=t-Dh8J9ZrXo&t=1s.
      (ii) The web-based data-entry portal: Our consumers were less interested in a PV site of which there are now 3 in Thailand, but a complete information source about HMs. In the context of very little knowledge about what herbals are being used, in what form, how they are used, what for, and the amount of relief obtained, PV information alone is superfluous.
      Our philosophy for the herbal medicines portal and data base is that consumers feel they are part of community-wide resources and share its ownership. Clearly, inputting data needs feedback in three forms (i) a simple text message, (ii) a telephone call from an expert seeking further information, (iii) on-line database query about other users’ experiences of the same medicine, or about other medicines.
      Smart phones are almost universally available to consumers and nearly all areas have 3G coverage and most have 4G. Web pages for smart phones are highly amenable for inputting simple data, while descriptions of symptoms requires more complex dialogue. So a balance between gleaning enough information to be useful and asking for too much causing the user to give up is a major problem.
      Many potential users aged >40 have very low educational attainment. This makes it problematic in deciding the range of information sought, the way questions are framed, and the method of data entry. To begin with, we are questionnairing experts in PV and herbal medicines to gain a consensus about essential information.

Teaching research

     Introduction of new teaching methods in any area of education, including in pharmacy teaching, has little evidence base. While teaching pharmacoepidemiology is mostly class room-based, we have sought to improve how undergraduates view the importance of pharmacoepidemiology in their professional lives and the role of pharmacy in health-care. Accordingly, we introduced a ‘hands-on’ research-based element as an education intervention trial about a trial.
     (i) Students recruited close relatives taking pharmaceuticals for chronic disease, and asked them about their difficulties in adhering to treatments. In the class, data collected by students was correlated, analysed, and summarised as the main outcome. From this, the students learned about processes involved in running a cohort study, while also understanding why patients have experience difficulties and lapses in adherence to treatment for chronic diseases.
     (ii) The students themselves were participants in a teaching trial where the primary end-point was their understanding and knowledge about relevant areas of pharmacoepidemiology as determined by a classroom-based examination, and by student comment about the teaching mode this sub-area within the course. Two trials using different protocols were run during non-consecutive years recruiting ~90 students each time.
          a. The first trial the entire cohort of students were given an examination, then ’treated’ with the research project after which the students were tested using another similar examination whereupon their scores doubled. (Download journal pdf here)
          b. The trial was run with another cohort recruited into two groups run as a cross-over design which circumvents a major ethical obstruction for intervention-based education studies, ie, all students must receive the same ‘treatment’ and opportunity to attain the same exam score.

Funding sources

     • International Research Network for Pharmacovigilance in Herbal Medicines. Source of funding: The Thailand Science Research and Innovation (TSRI)
     • Self-care of adverse experiences from the use of herbal medicines: a case study in Wang Mai Subdistrict, Na Yai Am District Chanthaburi Province. Source of funding: Annual government statement of expenditure 2017
     • Hospital admissions associated with non-adherence. Source of funding: Naresuan University Research Fund 2016 (THB 100,000)
     • Pharmacovigilance activities in ASEAN. Source of funding: Naresuan University Research Fund 2015
     • Thai Community Pharmacy and Health Insurance Systems: A systematic review. Source of funding: National Security Office, Thailand 2015
     • Amphur Wangthong Health District (Wangthong DHS) Project under the 24 Health District (24 DHS) Project: Source of funding: Thai Health Promotion Foundation, Thailand 2014
     • Safety culture of drug use across healthcare practitioners: a social network analysis. Source of funding: Annual government statement of expenditure
     • Hospital visits associated with drug-related problems at outpatient department in Thai elderly. Source of funding: Annual government statement of expenditure 2014
     • Drug use in Thai elderly, Lower Northern Region of Thailand. Source of funding: Foundation of Thai Gerontology Research and Development institute (TGRI)
     • Hospital admissions associated with drug-related problems in elderly. Source of funding: Annual government statement of expenditure
     • Cognitive effects of Bacopa monnieri extract: a systematic review and meta-analysis of randomized controlled trials. Source of funding: Naresuan University Research Fund
     • Associations between depression and adherence to diabetic treatment in children and adolescents: systematic review and meta-analysis. Source of funding: Naresuan University Research Fund

Contact us

Room 2312, Faculty of Pharmaceutical Science, Naresuan University, Phitsanulok, Thailand 65000
Tel: +66 5596 3730, +66 5596 3732 E-mail: sqhphanu@gmail.com