Administrative Personnel ; Health Personnel ; Health Policy ; Health Services Research ; Singapore

INTRODUCTIONChronic kidney disease (CKD) is a major public health problem where majority of patients are managed in the primary care. The major risk factors are advanced age, hypertension and diabetes mellitus, and risk factors control is paramount to prevent progression to CKD. The objective of the study is to describe the epidemiology and quality of care of patients with CKD stages 3 to 5 at National Healthcare Group Polyclinics (NHGP).

MATERIALS AND METHODSThe study was carried out using data from National Healthcare Group (NHG) Renal Registry. Patients were included if they were identified to have CKD based on ICD-9-CM codes and laboratory results.

RESULTSOverall, the number of CKD patients increased more than 2 fold from 4734 in 2007 to 10,245 in 2011. In 2011, the majority belonged to stages 3A (39.6%) and 3B (37.6%), had hypertension (98.2%), dyslipidemia (97.2%) and diabetes mellitus (68.7%). From 2007 to 2011, among those with hypertension, the use of angiotensin converting enzyme (ACE) inhibitors and/ or angiotensin receptor blockers increased from 78.4% to 84.1%, and the percentage with good systolic blood pressure control (<130 mmHg) improved from 18.7% to 36.3%. Among those with dyslipidemia, the use of statins increased from 81% to 87.1%, and the percentage of patients with low density lipoproteins (LDL) <2.6 mmol/L increased from 40% to 54.7%. However, among those with diabetes mellitus, mean glycated haemoglobin (HBA1c) increased from 7.4% to 7.6%, and the percentage of patients with HBA1c ≤7.0% decreased from 44.5% to 39.4%.

CONCLUSIONThe number of CKD patients in NHGP has increased significantly from 2007 to 2011 at an average annual rate of 21.3%. Majority of patients the study conducted in 2011 were in stage 3A and stage 3B. Blood pressure and LDL control are encouraging but glycaemic control can be further improved.

Humans ; Primary Health Care ; Quality of Health Care ; Registries ; Renal Insufficiency, Chronic ; drug therapy ; epidemiology ; Singapore ; epidemiology

Coronary heart disease is currently the leading cause of death globally, and is expected to account for 14.2% of all deaths by 2030. The emergence of novel technologies from cardiothoracic surgery and interventional cardiology are welcome developments in the light of an overwhelming chronic disease burden. However, as these complementary yet often competing disciplines rely on expensive technologies, hastily prepared resource plans threaten to consume a substantial proportion of limited healthcare resources. By describing procedural and professional trends as well as current and emerging technologies, this review aims to provide useful knowledge to help managers make informed decisions for the planning of cardiovascular disease management. Since their inception, developments in both specialties have been very rapid. Owing to differences in patient characteristics, interventions and outcomes, results of studies comparing cardiothoracic surgery and interventional cardiology have been conflicting. Outcomes for both specialties continue to improve through the years. Despite the persistent demand for coronary artery bypass surgery (CABG) as a rescue procedure following percutaneous coronary intervention (PCI), there is a widening gap between the numbers of PCI and CABG. Procedural volumes seem to have affected career choices of physicians. Emerging technologies from both disciplines are eagerly awaited by the medical community. For long-term planning of both disciplines, conventional health technology assessment methods are of limited use due to their rapid developments. In the absence of established prediction tools, planners should tap alternative sources of evidence such as changes in disease epidemiology, procedural volumes, horizon scan reports as well as trends in disease outcomes.
Cardiology ; trends ; Decision Making ; Humans ; Internationality ; Thoracic Surgery ; trends

INTRODUCTIONRoutine blood cultures have been recommended for all patients in treatment guidelines for community-acquired pneumonia (CAP). This practice has become a major area of resource utilisation, despite the lack of evidence in its clinical utility. Calls for abandoning the practice is balanced by the occasions of uncovering an unexpected pathogen or an unusual antimicrobial resistance pattern. The aim of this study is to identify factors that predict positive blood cultures among patients hospitalised for pneumonia upon presentation at the Emergency Department (ED).

MATERIALS AND METHODSA case control study was carried out on patients treated for pneumonia in the ED who had routine blood cultures performed as part of their management. The pneumonia severity index (PSI) was used to categorize patients into low- and high-risk for 30-day mortality. Logistic regression was carried out to determine factors significantly associated with positive blood cultures, from which a predictive probability equation was used to identify patients whose blood cultures were negative at a pre-determined cut-off, with minimum number of culture positive misclassification. A scoring system was devised, with scores predicting which patients would be likely to have a positive or negative blood culture.

RESULTSA total of 1407 patients with pneumonia were treated at ED from May to December 2006, from whom 1800 blood cultures were performed. Of these, 140 cultures (7.8%) grew organisms, comprising 96 (5.3%) true positive cultures and 44 (2.4%) contaminated cultures. Logistic regression analysis identified ill patients with higher PSI classes, smokers and Malay patients to be more likely to have positive blood cultures. Patients who had prior treatment with antibiotics, chronic obstructive pulmonary disease and cough were less likely to have positive blood cultures. An index to predict a negative blood culture resulted in the accurate classification of all but 4 positive patients while still correctly classifying 27.8% of blood culture negative patients. The area under the ROC curve was 0.71 (95% CI, 0.65-0.76). A simplified scoring system was devised based on the predictive model had a sensitivity of 82% and specificity of 38.2% for a positive blood culture.

CONCLUSIONRoutine blood cultures yielded negative results in 94% of patients presenting with pneumonia. The development of the clinical scoring system is a first step towards selecting patients for whom blood cultures is performed and improve cost-effectiveness.

Adult ; Aged ; Aged, 80 and over ; Case-Control Studies ; Community-Acquired Infections ; blood ; diagnosis ; Culture Techniques ; Emergency Service, Hospital ; Female ; Forecasting ; Gram-Negative Bacteria ; isolation & purification ; Gram-Positive Bacteria ; isolation & purification ; Humans ; Male ; Middle Aged ; Pneumonia ; blood ; diagnosis ; Regression Analysis ; Singapore ; Young Adult

INTRODUCTIONThis study aims to measure the quality of care for patients with diabetes mellitus at selected Specialist Outpatient Clinics (SOCs) in the National Healthcare Group.

MATERIALS AND METHODSThe cross-sectional study reviewed case-records of patients from 6 medical specialties who were on continuous care for a minimum of 15 months from October 2003 to April 2005. Disproportionate sampling of 60 patients from each specialty, excluding those co-managed by Diabetes Centres or primary care clinics for diabetes, was carried out. Information on demographic characteristics, process indicators and intermediate outcomes were collected and the adherence rate for each process indicator compared across specialties. Data analysis was carried out using SPSS version 13.0.

RESULTSA total of 575 cases were studied. The average rate for 9 process indicators by specialty ranged from 47.8% to 70.0%, with blood pressure measurement consistently high across all specialties (98.4%). There was significant variation (P <0.001) in rates across the specialties for 8 process indicators; HbA1c, serum creatinine and lipid profile tests were over 75%, while the rest were below 50%. The mean HbA1c was 7.3% +/- 1.5%. "Optimal" control of HbA1c was achieved in 51.2% of patients, while 50.6% of the patients achieved "optimal" low-density lipoprotein (LDL)-cholesterol control. However, 47.3% of patients had "poor" blood pressure control. Adherence to process indicators was not associated with good intermediate outcomes.

CONCLUSIONSThere was large variance in the adherence rate of process and clinical outcome indicators across specialties, which could be improved further.

Adult ; Aged ; Aged, 80 and over ; Cholesterol, LDL ; Cross-Sectional Studies ; Diabetes Mellitus ; therapy ; Female ; Glycated Hemoglobin A ; Hospitals, Public ; Humans ; Male ; Middle Aged ; Outcome Assessment (Health Care) ; Outpatient Clinics, Hospital ; Outpatients ; Patient Acceptance of Health Care ; Patient Compliance ; Quality of Health Care ; Retrospective Studies ; Singapore

INTRODUCTIONDepression in the elderly is a major public health issue. Socioeconomic status (SES) and social support are strong risk factors for depression. This study aimed to investigate the influence of SES and social support in elderly depression, and the modifying effect of social support on the relationship between SES and depression.

MATERIALS AND METHODSA community-based survey was conducted on residents≥60 years old. Depressive symptoms were determined with scores≥5 using the 15-item Geriatric Depression Scale (GDS). Multivariable logistic regression was performed to determine the odds ratio (OR) of depressive symptoms with respect to SES and social support, and interaction terms between the two variables.

RESULTSOf 2447 responses analysed, 188 (7.8%) respondents had depressive symptoms. Living in 2-room housing, living alone/with a domestic helper, infrequent leisure time with children/grandchildren or being childless, and feeling socially isolated were independently associated with depressive symptoms. Relative to residents living with spouse and children in 4-/5-room housing, the highest ORs for depressive symptoms were those living with spouse and children in 2-room (OR: 3.06, P<0.05), followed by living with children only in 3-room (OR: 2.98, P<0.05), and living alone/with a domestic helper in 4-/5-room (OR: 2.73, P<0.05). Living with spouse only appears to buffer against depressive symptoms across socioeconomic classes, although the effect was not statistically significant.

CONCLUSIONLow social support and low SES significantly increased the odds of depressive symptoms. The moderating effect of social support on depression was however not consistent across SES groups. Specific interventions need to target different SES groups to better help older adults at risk of developing depression.

Adult ; Aged ; Depression ; therapy ; Female ; Humans ; Middle Aged ; Singapore ; Social Class ; Social Support ; Surveys and Questionnaires

INTRODUCTIONThe outbreak of severe acute respiratory syndrome (SARS) began after the index case was admitted on 1 March 2003. We profile the cases suspected to have acquired the infection in Tan Tock Seng Hospital (TTSH), focussing on major transmission foci, and also describe and discuss the impact of our outbreak control measures.

MATERIALS AND METHODSUsing the World Health Organization (WHO) case definitions for probable SARS adapted to the local context, we studied all cases documented to have passed through TTSH less than 10 days prior to the onset of fever. Key data were collected in liaison with clinicians and through a team of onsite epidemiologists.

RESULTSThere were 105 secondary cases in TTSH. Healthcare staff (57.1%) formed the majority, followed by visitors (30.5%) and inpatients (12.4%). The earliest case had onset of fever on 4 March 2003, and the last case, on 5 April 2003. Eighty-nine per cent had exposures to 7 wards which had cases of SARS that were not isolated on admission. In 3 of these wards, major outbreaks resulted, each with more than 20 secondary cases. Attack rates amongst ward-based staff ranged from 0% to 32.5%. Of 13 inpatients infected, only 4 (30.8%) had been in the same room or cubicle as the index case for the ward.

CONCLUSIONSThe outbreak of SARS at TTSH showed the challenges of dealing with an emerging infectious disease with efficient nosocomial spread. Super-spreading events and initial delays in outbreak response led to widespread dissemination of the outbreak to multiple wards.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Cross Infection ; epidemiology ; prevention & control ; Disease Outbreaks ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Patient Isolation ; methods ; Retrospective Studies ; Severe Acute Respiratory Syndrome ; epidemiology ; prevention & control ; Singapore ; epidemiology

INTRODUCTIONThis study determines the associations between self-reported chronic conditions, limitations in activities of daily living and health-related quality of life (HRQoL) among community dwelling elderly in Singapore.

MATERIALS AND METHODSA population-based cross-sectional survey was conducted among a random sample of 4200 residents from 58 blocks of dwellings in Marine Parade housing estate between April and May 2011. A structured questionnaire was used to collect data on demographic characteristics; chronic disease profile, health screenings, healthcare utilisation, physical activity, activities of daily living (ADL) and functional ability and health related quality of life. Quality of life was assessed using European Quality of life 5 Domain (EQ-5D). Ordinary least squares (OLS) regression was used to identify independent predictors of health related quality of life.

RESULTSA total of 2454 respondents for included for analysis. Most of the respondents were females (57.2%) and aged between 65 and 74 years (48.5%). Among them, 79.1% of the respondents were Chinese. Approximately three-fourth (77.5%) of the survey respondents reported having at least one of the 13 chronic medical conditions; high blood pressure (57.7%), high blood cholesterol (51.6%), diabetes (22.9%) were the most commonly reported conditions. Independent predictors of HRQoL with greatest decrements in EQ-5D index and visual analog scores (VAS) were unemployment, self-reported depression, arthritis and osteoporosis and ADL limitations for activities such as "unable to shower", "unable to do housework" and elderly with depressive symptoms (GDS score≥5).

CONCLUSIONThe study had identified predictors of HRQoL in elderly Singapore residents and also provides community-based EQ-5D index and VAS scores associated with a wide variety of chronic conditions and ADL limitations.

Activities of Daily Living ; Aged ; Chronic Disease ; Cross-Sectional Studies ; Female ; Humans ; Independent Living ; Male ; Quality of Life ; Singapore

INTRODUCTIONChronic kidney disease (CKD) is a major public health problem in Singapore. Efforts are being made to right-site CKD care (stage 1 to 3) from specialist outpatient clinics (SOCs) to general practitioners (GPs) to ease congestion. This study aims to identify factors influencing screening and management of CKD among GPs in Singapore.

MATERIALS AND METHODSA survey was conducted among the 1202 GPs between April and September 2010. The survey questionnaire was developed in collaboration with experts in nephrology and general practice, it included questions about screening, awareness and management of CKD.

POPULATION STUDIEDGPs registered with the National Healthcare Group General Practitioner (NHG GP) partner database.

RESULTSThree hundred and two GPs completed the survey. A total of 70% of the respondents were males and with their median years of practice as 18. A total of 86% of them reported screening for CKD while 50% of GPs were confident of managing patients with CKD stage 1; and 38% of GPs are aware of CKD guidelines. Majority of GPs (64%) agreed that right-siting of early CKD patients would ease congestion at SOCs. Some of the obstacles in CKD management listed by the GPs were lack of patient trust, experience and communication with the specialist and the inability of the patient to pay.

CONCLUSIONGPs screen patients for CKD, however their awareness of guidelines is limited. Opportunities exist for improving physician recognition of CKD, awareness of CKD guidelines, improving collaborative care and reimbursement for the patient and the provider. This study has identified factors which when addressed could lead to wider acceptance of CKD right-siting by both the patients and the GPs.

Ambulatory Care Facilities ; utilization ; Female ; General Practice ; Health Care Surveys ; Health Knowledge, Attitudes, Practice ; Humans ; Male ; Practice Patterns, Physicians' ; statistics & numerical data ; Renal Insufficiency, Chronic ; diagnosis ; therapy ; Singapore

INTRODUCTIONOver the years, surveys have become powerful tools for assessing a wide range of outcomes among patients. Healthcare managers and professionals now consider patient satisfaction as an outcome by itself. This study aims to determine if results of a patient satisfaction survey are affected by the manner by which the survey instrument is administered.

MATERIALS AND METHODSA patient satisfaction survey was conducted from May 2006 to October 2007 in a tertiary level acute care facility. All patients admitted to the observation unit during the study period were invited to participate. Using a contextualized version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey, data was collected through either a phone interview, face to face interview or self-administered questionnaire. Each of these survey modes was administered during 3 different phases within the study period.

RESULTSEight hundred thirty-two (832) patients were included in the survey. Based on results of univariate analysis, out of the 18 questions, responses to 11 (61.1%) were related to survey mode. Face-to-face interview resulted in the greatest proportion of socially desirable responses (72.7%), while phone interview yielded the highest proportion of socially undesirable responses (63.3%). After controlling for possible confounders, logistic regression results showed that responses to 55.6% of the questions were affected by survey mode. Variations in response between phone interview and self-administered questionnaire accounted for 87.5% of the observed differences.

CONCLUSIONSResearchers must be aware that the choice of survey method has serious implications on results of patient satisfaction surveys.

Adult ; Emergency Service, Hospital ; Female ; Health Care Surveys ; methods ; Hospitals ; standards ; Humans ; Interviews as Topic ; Male ; Middle Aged ; Patient Satisfaction ; Quality Assurance, Health Care ; Singapore ; Young Adult