INTRODUCTIONThe Short Portable Mental Status Questionnaire (SPMSQ) is a brief cognitive screening instrument, which is easy to use by a healthcare worker with little training. However, the validity of this instrument has not been established in Singapore. Thus, the primary aim of this study was to determine the diagnostic performance of SPMSQ for screening dementia among patients attending outpatient cognitive assessment clinics and to assess whether the appropriate cut-off score varies by patient's age and education. A secondary aim of the study was to map the SPMSQ scores with Mini-Mental State Examination (MMSE) scores.

MATERIALS AND METHODSSPMSQ and MMSE were administered by a trained interviewer to 127 patients visiting outpatient cognitive assessment clinics at the Singapore General Hospital, Changi General Hospital and Tan Tock Seng Hospital. The geriatricians at these clinics then diagnosed these patients with dementia or no dementia (reference standard). Sensitivity and specificity of SPMSQ with different cut-off points (number of errors) were calculated and compared to the reference standard using the Receiver Operator Characteristic (ROC) analysis. Correlation coefficient was also calculated between MMSE and SPMSQ scores.

RESULTSBased on the ROC analysis and a balance of sensitivity and specificity, the appropriate cut-off for SPMSQ was found to be 5 or more errors (sensitivity 78%, specificity 75%). The cut-off varied by education, but not by patient's age. There was a high correlation between SPMSQ and MMSE scores (r = 0.814, P <0.0001).

CONCLUSIONDespite the advantage of being a brief screening instrument for dementia, the use of SPMSQ is limited by its low sensitivity and specificity, especially among patients with less than 6 years of education.

Age Factors ; Aged ; Aged, 80 and over ; Ambulatory Care Facilities ; statistics & numerical data ; Comparative Effectiveness Research ; Dementia ; diagnosis ; epidemiology ; psychology ; Educational Status ; Female ; Geriatric Assessment ; methods ; statistics & numerical data ; Humans ; Intelligence Tests ; standards ; statistics & numerical data ; Male ; Mass Screening ; methods ; standards ; Mental Competency ; Middle Aged ; ROC Curve ; Reference Standards ; Reproducibility of Results ; Singapore ; epidemiology

INTRODUCTIONIn the context of rapid population ageing and the increase in number of activity of daily living (ADL) limitations with age, the number of older persons requiring human assistance in Singapore is likely to grow. To promote informed planning for the needs of these elderly, we project the number of resident Singaporeans 60 years of age and older with 1 or more ADL limitations requiring human assistance through 2030.

MATERIALS AND METHODSThe proportion of community-dwelling older adults with ADL limitations requiring human assistance, stratified by gender and age group, was calculated utilising a recent nationally-representative survey of older Singaporeans. The proportion of older adults in nursing homes with ADL limitations was estimated based on available literature. Together, these prevalence estimates were applied to a simulation of the future population of older adults in Singapore to derive an estimate of the number of individuals with ADL limitations requiring human assistance through 2030.

RESULTSBy 2030, the number of resident Singaporeans aged 60 years or older with 1 or more ADL limitations requiring human assistance is projected to be 82,968 persons (7% of the total population aged 60 years or older). Of this number, 38,809 (47%) are estimated to have 1 or 2 ADL limitations, and 44,159 (53%) are estimated to have 3 or more.

CONCLUSIONThe number of elderly Singaporeans with activity limitations is expected grow rapidly from 31,738 in 2010 to 82,968 in 2030. Estimates of the number of older individuals with ADL limitations requiring human assistance are of value for policymakers as well as acute and long-term care capacity planners as they seek to meet demand for health and social services in Singapore.

Activities of Daily Living ; Aged ; Aged, 80 and over ; Female ; Forecasting ; Health Services for the Aged ; statistics & numerical data ; Homes for the Aged ; statistics & numerical data ; Humans ; Independent Living ; Long-Term Care ; statistics & numerical data ; trends ; Male ; Middle Aged ; Singapore

INTRODUCTIONTicagrelor is a novel antiplatelet drug developed to reduce atherothrombosis. The PLATO trial compared ticagrelor and aspirin to clopidogrel and aspirin in patients with acute coronary syndromes (ACS). Ticagrelor was found to be superior in the primary composite endpoint of cardiovascular death, myocardial infarction or stroke, without increasing major bleeding events. The current study estimates the lifetime cost-effectiveness of ticagrelor relative to generic clopidogrel from a Singapore public healthcare perspective.

METHODSThis study used a two-part cost-effectiveness model. The first part was a 12-month decision tree (using PLATO trial data) to estimate the rates of major cardiovascular events, healthcare costs and health-related quality of life. The second part was a Markov model estimating lifetime quality-adjusted survival and costs conditional on events during the initial 12 months. Daily drug costs applied were SGD 1.05 (generic clopidogrel) and SGD 6.00 (ticagrelor). Cost per quality-adjusted life years (QALY) was estimated from a Singapore public healthcare perspective using life tables and short-term costs from Singapore, and long-term costs from South Korea. Deterministic and probabilistic sensitivity analyses were performed.

RESULTSTicagrelor was associated with a lifetime QALY gain of 0.13, primarily driven by lower mortality. The resulting incremental cost per QALY gained was SGD 10,136.00. Probabilistic sensitivity analysis indicated that ticagrelor had a > 99% probability of being cost-effective, given the lower recommended WHO willingness-to-pay threshold of one GDP/capita per QALY.

CONCLUSIONBased on PLATO trial data, one-year treatment with ticagrelor versus generic clopidogrel in patients with ACS, relative to WHO reference standards, is cost-effective from a Singapore public healthcare perspective.

Acute Coronary Syndrome ; drug therapy ; economics ; Adenosine ; analogs & derivatives ; economics ; therapeutic use ; Aspirin ; administration & dosage ; Clinical Trials as Topic ; Cost-Benefit Analysis ; Decision Trees ; Drug Costs ; Humans ; Markov Chains ; Platelet Aggregation Inhibitors ; administration & dosage ; economics ; Purinergic P2Y Receptor Antagonists ; administration & dosage ; economics ; Quality-Adjusted Life Years ; Republic of Korea ; Singapore ; Ticlopidine ; administration & dosage ; analogs & derivatives

INTRODUCTION: Patients referred for chest pain from primary care have increased, along with demand for outpatient cardiology consultations. We evaluated 'Triage Protocol' that implements standardised diagnostic testing prior to patients' first cardiology consultation. MATERIALS AND METHODS: Under the 'Triage Protocol', patients referred for chest pain were pretriaged using a standardised algorithm and subsequently referred for relevant functional diagnostic cardiology tests before their initial cardiology consultation. At the initial cardiology consultation scheduled by the primary care provider, test results were reviewed. A total of 522 triage patients (mean age 55 ± 13, male 53%) were frequency-matched by age, gender and risk cohort to 289 control patients (mean age: 56 ± 11, male: 52%). Pretest risk of coronary artery disease was defined according to a Modified Duke Clinical Score (MDCS) as low (<10), intermediate (10-20) and high (>20). The primary outcome was time from referral to diagnosis (days). Secondary outcomes were total visits, discharge rate at first consultation, patient cost and adverse cardiac outcomes. RESULTS: The 'Triage Protocol' resulted in shorter times from referral to diagnosis (46 vs 131 days; <0.0001) and fewer total visits (2.4 vs 3.0; <0.0001). However, triage patients in low-risk groups experienced higher costs due to increased testing (S$421 vs S$357, = 0.003). Adverse cardiac event rates under the 'Triage Protocol' indicated no compromise to patient safety (triage vs control: 0.57% vs 0.35%; = 1.000). CONCLUSION By implementing diagnostic cardiac testing prior to patients' first specialist consultation, the 'Triage Protocol' expedited diagnosis and reduced subsequent visits across all risk groups in ambulatory chest pain patients.
Algorithms ; Cardiology Service, Hospital ; Chest Pain ; therapy ; Clinical Protocols ; Female ; Humans ; Male ; Middle Aged ; Primary Health Care ; Treatment Outcome ; Triage ; methods

Clinical practice guidelines (CPGs) have become ubiquitous in every field of medicine today but there has been limited success in implementation and improvement in health outcomes. Guidelines are largely based on the results of traditional randomised controlled trials (RCTs) which adopt a highly selective process to maximise the intervention's chance of demonstrating efficacy thus having high internal validity but lacking external validity. Therefore, guidelines based on these RCTs often suffer from a gap between trial efficacy and real world effectiveness and is one of the common reasons contributing to poor guideline adherence by physicians. "Real World Evidence" (RWE) can complement RCTs in CPG development. RWE-in the form of data from integrated electronic health records-represents the vast and varied collective experience of frontline doctors and patients. RWE has the potential to fill the gap in current guidelines by balancing information about whether a test or treatment works (efficacy) with data on how it works in real world practice (effectiveness). RWE can also advance the agenda of precision medicine in everyday practice by engaging frontline stakeholders in pragmatic biomarker studies. This will enable guideline developers to more precisely determine not only whether a clinical test or treatment is recommended, but for whom and when. Singapore is well positioned to ride the big data and RWE wave as we have the advantages of high digital interconnectivity, an integrated National Electronic Health Record (NEHR), and governmental support in the form of the Smart Nation initiative.
Big Data ; Electronic Health Records ; Evidence-Based Medicine ; Guideline Adherence ; Humans ; Practice Guidelines as Topic ; Practice Patterns, Physicians' ; Pragmatic Clinical Trials as Topic ; Precision Medicine ; Singapore

INTRODUCTIONSingapore's ageing population is likely to see an increase in chronic eye conditions in the future. This study aimed to estimate the burden of eye diseases among resident Singaporeans stratified for age and ethnicity by 2040.

MATERIALS AND METHODSPrevalence data on myopia, epiretinal membrane (ERM), retinal vein occlusion (RVO), age macular degeneration (AMD), diabetic retinopathy (DR), cataract, glaucoma and refractive error (RE) by age cohorts and educational attainment from the Singapore Epidemiology of Eye Diseases (SEED) study were applied to population estimates from the Singapore population model.

RESULTSAll eye conditions are projected to increase by 2040. Myopia and RE will remain the most prevalent condition, at 2.393 million (2.32 to 2.41 million) cases, representing a 58% increase from 2015. It is followed by cataract and ERM, with 1.33 million (1.31 to 1.35 million), representing an 81% increase, and 0.54 million (0.53 to 0.549 million) cases representing a 97% increase, respectively. Eye conditions that will see the greatest increase from 2015 to 2040 in the Chinese are: DR (112%), glaucoma (100%) and ERM (91.4%). For Malays, DR (154%), ERM (136%), and cataract (122%) cases are expected to increase the most while for Indians, ERM (112%), AMD (101%), and cataract (87%) are estimated to increase the most in the same period.

CONCLUSIONResults indicate that the burden for all eye diseases is expected to increase significantly into the future, but at different rates. These projections can facilitate the planning efforts of both policymakers and healthcare providers in the development and provision of infrastructure and resources to adequately meet the eye care needs of the population. By stratifying for age and ethnicity, high risk groups may be identified and targeted interventions may be implemented.

BACKGROUNDPrevalence of atrial fibrillation (AF) is increasing as the world ages. AF is associated with higher risk of mortality and disease, including stroke, hypertension, heart failure, and dementia. Prevalence of AF differs with each population studied, and research on non-Western populations and the oldest old is scarce.

METHODSWe used data from the 2012 wave of the Chinese Longitudinal Healthy Longevity Survey, a community-based study in eight longevity areas in China, to estimate AF prevalence in an elderly Chinese population (n = 1418, mean age = 85.6 years) and to identify risk factors. We determined the presence of AF in our participants using single-lead electrocardiograms. The weighted prevalence of AF was estimated in subjects stratified according to age groups (65-74, 75-84, 85-94, 95 years and above) and gender. We used logistic regressions to determine the potential risk factors of AF.

RESULTSThe overall prevalence of AF was 3.5%; 2.4% of men and 4.5% of women had AF (P < 0.05). AF was associated with weight extremes of being underweight or overweight/obese. Finally, advanced age (85-94 years), history of stroke or heart disease, low high-density lipoprotein levels, low triglyceride levels, and lack of regular physical activity were associated with AF.

CONCLUSIONSIn urban elderly, AF prevalence increased with age (P < 0.05), and in rural elderly, women had higher AF prevalence (P < 0.05). Further exploration of population-specific risk factors is needed to address the AF epidemic.

Aged ; Aged, 80 and over ; Atrial Fibrillation ; epidemiology ; China ; epidemiology ; Female ; Humans ; Longitudinal Studies ; Male ; Prevalence ; Risk Factors

INTRODUCTION: The identification of population-level healthcare needs using hospital electronic medical records (EMRs) is a promising approach for the evaluation and development of tailored healthcare services. Population segmentation based on healthcare needs may be possible using information on health and social service needs from EMRs. However, it is currently unknown if EMRs from restructured hospitals in Singapore provide information of sufficient quality for this purpose. We compared the inter-rater reliability between a population segment that was assigned prospectively and one that was assigned retrospectively based on EMR review. METHODS: 200 non-critical patients aged ≥ 55 years were prospectively evaluated by clinicians for their healthcare needs in the emergency department at Singapore General Hospital, Singapore. Trained clinician raters with no prior knowledge of these patients subsequently accessed the EMR up to the prospective rating date. A similar healthcare needs evaluation was conducted using the EMR. The inter-rater reliability between the two rating sets was evaluated using Cohen's Kappa and the incidence of missing information was tabulated. RESULTS: The inter-rater reliability for the medical 'global impression' rating was 0.37 for doctors and 0.35 for nurses. The inter-rater reliability for the same variable, retrospectively rated by two doctors, was 0.75. Variables with a higher incidence of missing EMR information such as 'social support in case of need' and 'patient activation' had poorer inter-rater reliability. CONCLUSION Pre-existing EMR systems may not capture sufficient information for reliable determination of healthcare needs. Thus, we should consider integrating policy-relevant healthcare need variables into EMRs.