Ensuring timely access to specialist care is an important indicator of the quality of a health service. Demand for cardiology outpatient appointments has grown considerably in the last decade, leading to increased waiting time for cardiology appointments at public hospitals. This paper examines the effectiveness of past and ongoing strategies initiated by the National Heart Centre, many of which were in collaboration with SingHealth Polyclinics, documents the lessons learnt, and provides a framework for approaching this problem. Instead of a simplistic approach where institutions react to long waiting times by growing capacity to meet demand, this paper emphasises the need to focus on the final intended outcome (timely diagnosis and treatment) rather than on a single performance indicator, such as waiting time. A broad systems approach at the national level is advocated, rather than piecemeal, uncoordinated actions by individual hospitals.
Ambulatory Care Facilities ; Cardiology ; Cardiovascular Diseases ; therapy ; Cooperative Behavior ; Efficiency, Organizational ; Health Services Accessibility ; Health Services Needs and Demand ; Humans ; Primary Health Care ; Referral and Consultation ; trends ; Singapore

The Singapore public healthcare system has increasingly used the term "right-siting" to describe the principle that stable chronic disease patients should be managed in primary care rather than specialist settings. The majority of primary healthcare providers in Singapore are general practitioners (GPs). The aims of this paper were to measure the quality of diabetes care in specialist and GP settings, and assess right-siting efforts in a tertiary centre in Singapore. Three hundred eighty-three consecutive patients with type 2 diabetes referred to the Singapore General Hospital Diabetes Centre (SGH DBC) between January and March 2005 were analysed. At the first visit, 51 patients (13.3%) were classified as inappropriate referrals and discharged back to the referral source or to primary care. After 12 months, 136 patients (group A = 35.5%) remained on follow-up at SGH DBC. In these patients, significant improvements were seen in mean HbA1c but not blood pressure (BP) or low density lipoprotein-cholesterol (LDL-C). One hundred twenty-eight (group B = 33.4%) patients were discharged from DBC within the 12 months of the study period. Mean follow-up duration in group B was 5.5 months and HbA1c, blood pressure and LDL-cholesterol had improved significantly in these patients. Glycaemic control of group B patients at the time of discharge was significantly better than group A at 12 months (mean HbA1c = 7.15% vs 8.16%; P <0.001). More than half (55.6%) of group B patients achieved HbA1c targets compared to 32.4% from group A (P <0.001). Although mean BP and LDL-C levels fell in group B patients, the percentage of patients achieving BP and LDL-C targets did not improve significantly in both groups. From August 2005 to January 2008, GPs participating in SingHealth's Delivering on Target (DOT) programme enrolled 579 patients under their care for additional diabetic counselling by community nurse educators. Pre- and post-programme HbA1c results were submitted for 370 patients (64%). Mean HbA1c levels of these patients decreased from 8.23% to 7.32% (P <0.001). The proportion of patients who achieved HbA1c <7% increased from 26% to 51% (P <0.01). However, BP and LDL-C levels did not improve. It is difficult to base referral or discharge decisions solely on these indicators. Our studies show that both in the specialist and GP settings, significant improvements in HbA1c are seen. Results for BP and LDL-C, however, showed little improvement. Some degree of rightsiting was seen at SGH DBC with discharged patients showing greater improvements than patients who were retained. However, >30% of patients remained in SGH DBC despite achieving HbA1C targets. Our results indicate the need for better strategies to address the underlying obstacles to right-siting. Of greater concern, the lack of improvement in BP and LDL-C indicates a high degree of clinical inertia to these issues among specialists and GPs treating diabetes in Singapore.
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Blood Glucose ; metabolism ; Blood Pressure ; Cholesterol, LDL ; blood ; Delivery of Health Care, Integrated ; methods ; standards ; Diabetes Mellitus ; blood ; physiopathology ; therapy ; Female ; Follow-Up Studies ; Glycated Hemoglobin A ; metabolism ; Humans ; Middle Aged ; Outcome Assessment (Health Care) ; methods ; Primary Health Care ; methods ; standards ; Retrospective Studies ; Singapore ; Young Adult

INTRODUCTIONIncreasing demand for public healthcare and access to specialist care has become a major concern. Characterising the referral pattern to a national centre's cardiology specialist outpatient clinics (SOCs) and the diagnostic outcomes may be useful in formulating referral guidelines to contain rising demand.

MATERIALS AND METHODSA prospective observational followup study was conducted of all consecutive new patient referrals to the cardiology SOCs of the National Heart Centre over a 1-month period. The records of these 1224 patients were reviewed following their first visit and again after 3 months of evaluation and investigation. Patients' demographics, referral sources, indications of referral, risk factors, provisional and final diagnoses were collected. Referrals from the top 2 volume sources (government polyclinics and hospital Emergency Department) accounted for 600 referrals. These subsidised referrals formed the study group for analysis.

RESULTSThe mean age of referred patients was 56 +/- 15.2 years, with equal proportion of males and females. Most patients had known cardiac risk factors of hypertension (53.2%) and hyperlipidaemia (42.3%). Only 23% of referrals had significant cardiac abnormalities. Referrals for typical chest pain derived the highest yield whereas referrals for atypical chest pain, non-cardiac chest pain derived the lowest yield. Referrals for asymptomatic electrocardiogram (ECG) changes (except for atrial flutter/fibrillation) did not yield cardiac abnormalities. Multivariate analysis of chest pain referrals showed typical chest pain and hyperlipidaemia to be statistically significant predictors for coronary artery disease.

CONCLUSIONReferrals to cardiology outpatient specialist clinics should be based on the presence of patient symptoms, particularly that of typical chest pain. In asymptomatic patients, routine ECG screening did not appear to yield significant cardiac abnormalities.

Adult ; Aged ; Ambulatory Care Facilities ; Cardiology ; Cardiovascular Diseases ; diagnosis ; physiopathology ; Female ; Health Services Needs and Demand ; Humans ; Male ; Medicine ; Middle Aged ; Prospective Studies ; Referral and Consultation ; economics ; utilization ; Singapore ; Specialization

INTRODUCTIONThe study was designed to reduce door-to-balloon times in primary percutaneous coronary intervention for patients presenting to the Emergency Department with acute ST-elevation myocardial infarction, using an audit as a quality initiative.

MATERIALS AND METHODSA multidisciplinary work group performed a pilot study over 3 months, then implemented various process and work-flow strategies to improve overall door-to-balloon times.

RESULTS AND CONCLUSIONWe developed a guideline-based, institution-specific written protocol for triaging and managing patients who present to the Emergency Department with symptoms suggestive of STEMI, resulting in shortened median door-to-balloon times from 130.5 to 109.5 minutes (P<0.001).

Angioplasty, Balloon, Coronary ; Emergency Service, Hospital ; statistics & numerical data ; utilization ; Health Care Surveys ; Humans ; Medical Audit ; Myocardial Infarction ; physiopathology ; therapy ; Pilot Projects ; Program Development ; Quality Indicators, Health Care ; Quality of Health Care ; Singapore ; Time Factors ; Triage

Objectives: To 1) report prevalence of ‘osteosarcopenia’ (OS) and osteosarcopenic obesity (OSO) entities using evidence-based diagnostic techniques and definitions, 2) examine if OSO offers additional predictive value of functional decline over its components, and 3) identify associated factors in a multi-racial Southeast Asian population. Methods: We performed a cross-sectional study of a representative sample of 542 community-dwelling adults (21–90 years old), and assessed anthropometry, cognition, functional performance, and self-report sociodemographic, health and lifestyle questionnaires. Low muscle mass, and the Asian Working Group for Sarcopenia (AWGS) 2019 criteria, were used to assess sarcopenia. Obesity was defined using percentage body fat and fat mass index. Osteopenia/osteoporosis was determined using lumbar spinal bone mineral density. Associated factors were examined using logistic regression, and OSO’s value investigated using linear regressions with functional performance. Results: OS and OSO prevalence were 1.8% and 0% (21–59 years), 12.9% and 2.8% (≥ 60 years), 17.3% and 4.1% (≥ 65 years), and 25.5% and 7.0% (≥75 years), respectively. OSO entity as defined was not a significant predictor (P > 0.05) and did not improve explanations for functional decline over sarcopenia or sarcopenic obesity. Age, sex, race and body mass index (BMI) were associated with OS, while age, sex, race and alcoholism were associated with OSO. Conclusions Our results do not support OSO as a distinct entity in relation to functional decline. Aside from biological age, sex, and race, amenable lifestyle factors such as BMI and alcohol intake are important variables that can influence the co-existence of osteopenia/osteoporosis, sarcopenia and obesity.

Objectives: To 1) report prevalence of ‘osteosarcopenia’ (OS) and osteosarcopenic obesity (OSO) entities using evidence-based diagnostic techniques and definitions, 2) examine if OSO offers additional predictive value of functional decline over its components, and 3) identify associated factors in a multi-racial Southeast Asian population. Methods: We performed a cross-sectional study of a representative sample of 542 community-dwelling adults (21–90 years old), and assessed anthropometry, cognition, functional performance, and self-report sociodemographic, health and lifestyle questionnaires. Low muscle mass, and the Asian Working Group for Sarcopenia (AWGS) 2019 criteria, were used to assess sarcopenia. Obesity was defined using percentage body fat and fat mass index. Osteopenia/osteoporosis was determined using lumbar spinal bone mineral density. Associated factors were examined using logistic regression, and OSO’s value investigated using linear regressions with functional performance. Results: OS and OSO prevalence were 1.8% and 0% (21–59 years), 12.9% and 2.8% (≥ 60 years), 17.3% and 4.1% (≥ 65 years), and 25.5% and 7.0% (≥75 years), respectively. OSO entity as defined was not a significant predictor (P > 0.05) and did not improve explanations for functional decline over sarcopenia or sarcopenic obesity. Age, sex, race and body mass index (BMI) were associated with OS, while age, sex, race and alcoholism were associated with OSO. Conclusions Our results do not support OSO as a distinct entity in relation to functional decline. Aside from biological age, sex, and race, amenable lifestyle factors such as BMI and alcohol intake are important variables that can influence the co-existence of osteopenia/osteoporosis, sarcopenia and obesity.