INTRODUCTION: As the population ages, patient complexity is increasing, intensifying the demand for well-resourced, coordinated care. A deeper understanding of the factors contributing to this complexity is essential for optimising resource allocation. This study evaluates the prevalence of complex care needs in Singapore's primary care settings and identifies the factors associated with these needs. METHOD: Using a qualitative study design, we developed a patient complexity questionnaire to assess how Singapore family physicians recognise patient complexity. Sixty-nine experienced primary care physicians applied this tool to assess patient encounters, categorising each as "routine care" (RC), "medically challenging" (MC), or "complex care" (CC). We compared the care needs across these categories and used mixed-effects multinomial logistic regression to determine the independent predictors of complexity. RESULTS: Of the 4327 encounters evaluated, 15.0% were classified as CC, 18.5% as MC, and 66.4% as RC. In both CC and MC encounters, the most common medical challenges were polypharmacy (66.2% in CC, 44.9% in MC); poorly controlled chronic conditions (41.3% in CC, 24.5% in MC); and treatment interactions (34.4% in CC, 26.0% in MC). Non-medical issues frequently identified included low health literacy (32.6% in CC, 20.8% in MC); limited motivation for healthy lifestyle behaviours (27.2% in CC, 16.6% in MC); and the need for coordinated care with hospital specialists (24.7% in CC, 17.1% in MC). The top 3 independent predictors of complexity included mobility limitations requiring assistance (odds ratio [OR] for requiring wheelchair/trolley: 7.14 for CC vs RC, 95% confidence interval [CI] 4.74-10.74); longer consultation times with physicians (OR for taking >20 minutes for doctor's consultation: 3.96 for CC vs RC, 95% CI 2.86-5.48); and low socioeconomic status (OR for living in 1- or 2-room HDB flats: 2.98 for CC vs RC, 95% CI 1.74-5.13). CONCLUSION High care needs, encompassing both CC and MC encounters, were prevalent in primary care interactions. These findings highlight that relying solely on chronic disease count is insufficient to capture the full spectrum of patient complexity.
Singapore/epidemiology* ; Humans ; Primary Health Care/statistics & numerical data* ; Male ; Female ; Middle Aged ; Aged ; Adult ; Surveys and Questionnaires ; Prevalence ; Polypharmacy ; Qualitative Research ; Chronic Disease/therapy* ; Logistic Models

INTRODUCTION: Comparison of patient health-related quality of life (HRQOL) scores to a reference group is needed to quantify the HRQOL impact of disease or treatment. This study aimed to establish population norms for 2 HRQOL questionnaires-EuroQol 5-dimension 5-level questionnaire (EQ-5D-5L) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core Question-naire 30 (EORTC QLQ-C30) according to age, sex and ethnicity-and to explore relationships between the EQ-5D-5L, EORTC QLQ-C30 and sociodemographic characteristics. We used a representative sample of adult Singapore residents aged 21 years and above. METHOD: This study used data collected from a cross-sectional household survey in which 600 adult Singaporeans completed questions on sociodemo-graphic characteristics-the EQ-5D-5L and the EORTC QLQ-C30. Multiple linear regression analyses were conducted to explore associations between sociodemographic characteristics, the EQ-5D-5L scores and the EORTC QLQ-C30 scores. Regression-based population norms were computed for each subgroup using a post-stratification method. RESULTS: In multiple linear regression analysis, age was significantly associated with EQ-5D-5L index and visual analogue scale (VAS) scores, while no sociodemographic characteristics were significantly associated with EORTC QLQ-C30 summary scores. The normative EQ-5D-5L index and VAS scores decreased in adults aged 65 years and above, and EQ-5D-5L index scores were slightly lower in females than males and in non-Chinese than Chinese. The normative EORTC QLQ-C30 summary scores were slightly higher in Chinese than in the non-Chinese group and in the 45-64 age group than other age groups. CONCLUSION This study provides population norms for the EQ-5D-5L and EORTC QLQ-C30 for the general adult population in Singapore. Future studies of patient populations in Singapore using EQ-5D-5L or QLQ-C30 can use these normative data to interpret the HRQOL data collected.
Humans ; Quality of Life ; Singapore ; Male ; Female ; Middle Aged ; Adult ; Cross-Sectional Studies ; Aged ; Surveys and Questionnaires ; Young Adult ; Health Status ; Age Factors ; Linear Models ; Aged, 80 and over

INTRODUCTION: Degenerative mitral stenosis (DMS) is frequently cited as increasing in prevalence in the developed world, although comparatively little is known about DMS in comparison to rheumatic mitral stenosis (RMS). METHOD: A retrospective observational study was conducted on 745 cases of native-valve mitral stenosis (MS) with median follow-up time of 7.25 years. Clinical and echocardiographic parameters were compared. Univariate and multivariate Cox regression analyses were performed for a composite of all-cause mortality and heart failure hospitalisation. RESULTS: Patients with DMS compared to RMS were older (age, mean ± standard deviation: 69.6 ± 12.3 versus [vs] 51.6 ± 14.3 years, respectively; P<0.001) and a greater proportion had medical comorbidities such as diabetes mellitus (78 [41.9%] vs 112 [20.0%], P<0.001). The proportion of cases of degenerative aetiology increased from 1.1% in 1991-1995 to 41.0% in 2016-2017. In multivariate analysis for the composite outcome, age (hazard ratio [HR] 95% confidence interval [CI] of 1.032 [1.020-1.044]; P<0.001), diabetes mellitus (HR 1.443, 95% CI 1.068-1.948; P=0.017), chronic kidney disease (HR 2.043, 95% CI 1.470-2.841; P<0.001) and pulmonary artery systolic pressure (HR 1.019, 95% CI 1.010- 1.027; P<0.001) demonstrated significant indepen-dent associations. The aetiology of MS was not independently associated with the composite outcome. CONCLUSION DMS is becoming an increasingly common cause of native-valve MS. Despite numerous clinical differences between RMS and DMS, the aetiology of MS did not independently influence a composite of mortality or heart failure hospitalisation.
Humans ; Mitral Valve Stenosis/etiology* ; Male ; Female ; Retrospective Studies ; Middle Aged ; Aged ; Rheumatic Heart Disease/mortality* ; Echocardiography ; Hospitalization/statistics & numerical data* ; Heart Failure/epidemiology* ; Singapore/epidemiology* ; Proportional Hazards Models ; Diabetes Mellitus/epidemiology*

INTRODUCTION: Outcomes after SARS-CoV-2 Omicron infection in patients with heart failure (HF) and ischaemic heart disease (IHD) remain poorly defined. METHOD: In a highly vaccinated cohort of adult Singapore citizens and permanent residents, we used Cox proportional hazards models (adjusted for sociodemographic variables and comorbidities) to compare the risks of Omicron infection, COVID-19- related hospitalisation, and severe COVID-19 between indivi-duals with HF or IHD and matched controls without these conditions. RESULTS: From national databases, we identified 15,426 HF patients matched 1:∼3 to 41,221 controls, and 110,442 IHD patients matched 1:∼2 to 223,843 controls. Over 80% of HF and IHD patients had received at least 3 vaccine doses. During the Omicron-predominant period, both HF and IHD cohorts demonstrated higher adjusted risks of COVID-19 hospitalisation compared with matched controls (HF: adjusted hazard ratio [aHR] 1.77, 95% confidence interval [CI] 1.65-1.90; IHD: aHR 1.21, 95% CI 1.17-1.26). Among those with at least 1 HF-or IHD-related admission in the prior year, hospitalisation risk was further elevated (HF: aHR 1.27, 95% CI 1.13-1.42; IHD: aHR 1.11, 95% CI 1.01-1.23). Receipt of ≥3 vaccine doses was associated with substantially lower risk of severe COVID-19 versus only 2 doses (HF: aHR 0.35, 95% CI 0.28-0.43; IHD: aHR 0.27, 95% CI 0.23-0.32). A fourth dose conferred additional reductions in infection and adverse outcomes, though CIs for infection overlapped with those for 3 doses. CONCLUSION During Omicron predominance, HF and IHD patients experienced greater risk of COVID-19 hospitalisation and severe COVID-19 versus matched controls. Booster vaccinations attenuated these risks. Individuals with recent HF/IHD admissions should be prioritised for receipt of booster vaccine doses.
Humans ; COVID-19/complications* ; Male ; Heart Failure/complications* ; Myocardial Ischemia/complications* ; Female ; Middle Aged ; Hospitalization/statistics & numerical data* ; Aged ; COVID-19 Vaccines/administration & dosage* ; Singapore/epidemiology* ; SARS-CoV-2 ; Proportional Hazards Models ; Adult ; Case-Control Studies ; Vaccination/statistics & numerical data*

INTRODUCTION: Preterm birth (PTB) remains a leading cause of perinatal morbidity and mortality worldwide. Understanding Singapore's PTB trends and associated risk factors can inform effective strategies for screening and intervention. This study analyses PTB trends in Singapore from 2017 to 2023, identifies risk factors in this multi-ethnic population and evaluates a predictive model for PTB. METHOD: A retrospective analysis of all PTBs between 22+0 and 36+6 weeks of gestation, from 1 January 2017 to 31 December 2023, was performed by extracting maternal and neonatal data from electronic medical records. These PTBs were taken from the registry of births for Singapore and SingHealth cluster data. Cochran- Armitage trend test and multinomial logistic regression were used. An extreme gradient boosting (XGBoost) model was developed to test and predict the risk of PTB. RESULTS: The PTB rate in Singapore did not show a significant change. However, there was modest downward trend in the SingHealth population from 11.3% to 10.2%, mainly in late spontaneous PTBs (sPTBs). sPTBs accounted for ∼60% of PTBs. Risk factors for very/extreme sPTB included Chinese ethnicity, age ≥35 years, body mass index (BMI) ≥23 kg/m², being unmarried, primiparity, twin pregnancy and maternal blood group AB. The XGBoost model achieved an area under the receiver operating characteristic curve of 0.75, indicating moderate ability to predict PTB. CONCLUSION The overall PTB rate in Singapore has not improved. This study underscores the importance of local factors, particularly advanced maternal age, BMI, primiparity, unmarried, Chinese ethnicity and maternal blood group AB influencing PTB risk. Artificial intelligence methods show promise in improving PTB risk stratification, ultimately supporting personalised care and intervention.
Humans ; Singapore/epidemiology* ; Retrospective Studies ; Female ; Risk Factors ; Premature Birth/ethnology* ; Pregnancy ; Adult ; Infant, Newborn ; Asian People/statistics & numerical data* ; Gestational Age ; Body Mass Index ; Maternal Age ; Logistic Models ; Ethnicity

INTRODUCTION: The 30-day readmission rate for chronic obstructive pulmonary disease (COPD) is a common performance metric but may be confounded by factors unrelated to quality of care. Our aim was to assess how sociodemographic factors, multimorbidity and frailty impact 30-day readmission risk after COPD hospitalisation, and whether risk adjustment alters interpretation of temporal trends. METHOD: This is a retrospective analysis of administra-tive data from October 2017 to June 2023 from Changi General Hospital, Singapore. Multivariable mixed-effects logistic regression models were used to estimate unadjusted and risk-adjusted 30-day readmission odds. Covariates included age, sex, race, Charlson Comorbidity Index (CCI), Hospital Frailty Risk Score (HFRS) and year. Temporal trends in readmission risk were compared across unadjusted and adjusted models. RESULTS: Of the 2774 admissions, 749 (27%) resulted in 30-day readmissions. Higher CCI (CCI≥4 versus [vs] CCI=1: adjusted odds ratio [aOR] 2.00, 95% confidence interval [CI] 1.33-2.99, P=0.003; CCI 2-3 vs CCI=1: aOR 1.50, 95% CI 1.15-1.96, P=0.001) and higher HFRS (≥5 vs <5: aOR 1.29, 95% CI 1.01-1.65, P=0.04) were independently associated with increased readmission risk. While unadjusted analyses showed no significant temporal trends, the risk-adjusted model revealed a 32-35% reduction in readmission odds in 2021-2023 compared to baseline. CONCLUSION Multimorbidity and frailty significantly impact COPD readmissions. Risk adjustment revealed improvements in readmission risk not evident in unadjusted analyses, emphasising the importance of applying risk adjustments to ensure valid performance metrics.
Humans ; Pulmonary Disease, Chronic Obstructive/therapy* ; Patient Readmission/trends* ; Male ; Female ; Retrospective Studies ; Aged ; Singapore/epidemiology* ; Multimorbidity ; Frailty/epidemiology* ; Middle Aged ; Risk Adjustment ; Aged, 80 and over ; Logistic Models ; Risk Factors

INTRODUCTION: Conservative kidney management (CKM) is a recognised treatment option for selected patients with chronic kidney disease stage 5 (CKD G5), but prognostic indicators for mortality and optimal timing for palliative care transition remain uncertain. METHOD: This is a single-centre, prospective cohort study of CKD G5 patients who opted for CKM, conducted between April 2021 and September 2024, with longitudinal monitoring of Edmonton Symptom Assessment System Revised: Renal; Palliative Perfor-mance Scale (PPS); Resources Utilisation Group.Activities of Daily Living (RUG-ADL) scale; Clinical Frailty Score; Karnofsky Performance Score; and clinical and laboratory data. Primary outcomes included identifying baseline mortality predictors and validating the PPS for survival estimation. Cox proportional hazards models were used to identify independent predictors of mortality. RESULTS: Among 109 patients (mean age 79.8±7.3 years, 64.2% female), 62 (56.9%) died during follow-up. Multivariate analysis identified baseline estimated glomerular filtration rate (eGFR) (hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.08.1.68, P<0.01) and serum albumin (HR 1.24, 95% CI 1.08.1.43, P<0.01) as predictors of 1-year mortality. Median survival varied by eGFR: 3.0 months (95% CI 0.6.2) for eGFR .5 mL/min/1.73 m², 13.0 months (95% CI 9.1.16.9) for eGFR 6.10 mL/ min/1.73 m², and 20.0 months (95% CI 16.5.23.5) for eGFR >10 mL/min/1.73 m² (P<0.01). Subsequent PPS correlated strongly with survival, with median survival of 1.8 months for PPS <50, 5.3 months for PPS 50.60, and 7.9 months for PPS 70.80 (P=0.03). CONCLUSION Baseline eGFR and serum albumin predict 1-year mortality in CKM patients. PPS offers a practical tool for identifying patients requiring palliative care transition, supporting personalised care pathways and timely integration of palliative care.
Humans ; Female ; Male ; Aged ; Prospective Studies ; Glomerular Filtration Rate ; Palliative Care/methods* ; Conservative Treatment/methods* ; Aged, 80 and over ; Prognosis ; Serum Albumin/analysis* ; Proportional Hazards Models ; Activities of Daily Living ; Singapore/epidemiology*

INTRODUCTION: Endometriosis (EMS) is a common gynaecological disorder linked to metabolic disturbances. However, evidence on the associations between lipid accumulation product (LAP) and visceral adiposity index (VAI) with the risk of EMS remains limited. This study aimed to explore the potential associations between LAP, VAI and EMS. METHOD: Data were obtained from the 1999-2006 National Health and Nutrition Examination Survey (NHANES), including a total of 2046 samples. Weighted multivariable logistic regression models and smoothed curve fitting were used to assess the associations between LAP, VAI and EMS. Additionally, subgroup analyses and interaction tests were conducted to evaluate intergroup differences in the associations between LAP, VAI and EMS. RESULTS: In the fully adjusted model, higher Log2 LAP (odds ratio [OR] 1.256, 95% confidence interval [CI] 1.102-1.431, P=0.0014) and Log2 VAI (OR 1.287, 95% CI 1.105-1.498, P=0.0022) were significantly associated with increased EMS risk. Participants in the highest quartile of Log2 LAP (OR 1.983, P=0.0029) and Log2 VAI (OR 1.690, P=0.0486) had a higher risk of EMS. Subgroup analysis showed stronger associations among women with diabetes (Log2 LAP OR 3.681, P=0.009; Log2 VAI OR 4.849, P=0.041). CONCLUSION Elevated LAP and VAI were independently associated with an increased risk of EMS. LAP and VAI may serve as potential indicators for assessing EMS-related risk, suggesting that visceral obesity and lipid metabolic disturbances might play roles in the pathophysiological process of EMS. These findings underscore the potential of LAP and VAI as non-invasive markers for EMS risk, warranting further validation in clinical settings.
Humans ; Female ; Cross-Sectional Studies ; Endometriosis/metabolism* ; Adult ; Nutrition Surveys ; Intra-Abdominal Fat ; Lipid Accumulation Product ; Middle Aged ; Obesity, Abdominal/complications* ; Adiposity ; Risk Factors ; Logistic Models

BACKGROUND: Huaier granule is an important medicinal fungus extract widely used in cancer treatment. Previous retrospective studies have reported its effectiveness in breast cancer patients, but the imbalanced baseline characteristics of participants could have biased the results. Therefore, this retrospective study aimed to examine the efficacy of Huaier granule on the prognosis of breast cancer patients. METHODS: In this single-center cohort study, breast cancer patients diagnosed and treated at the Guangdong Provincial Hospital of Chinese Medicine between 2009 and 2017 were selected. The data were retrospectively analyzed and divided into two groups according to whether the patients received Huaier granules. The propensity score matching (PSM) method was used to eliminate selection bias. The disease-free survival (DFS) and overall survival (OS) for these groups were compared using the Kaplan-Meier method and the Cox regression. RESULTS: This study included 214 early invasive breast cancer patients, 107 in the Huaier group and 107 in the control group. In the Kaplan-Meier analysis, the 2-year and 5-year DFS rates were significantly different in the Huaier group and control group (hazard ratio [HR], 0.495; 95% confidence interval [CI], 0.257-0.953; P = 0.023). The 2-year and 5-year OS rates were also significantly different (HR, 0.308; 95% CI, 0.148-0.644; P = 0.001). On multivariable Cox regression, Huaier granule was associated with improved DFS (HR, 0.440; 95% CI, 0.223-0.868; P = 0.018) and OS (HR, 0.236; 95% CI, 0.103-0.540; P = 0.001). CONCLUSION In this retrospective study, Huaier granules improved the DFS and OS of early invasive breast cancer patients, providing real-world evidence for further prospective studies on treating breast cancer with Huaier granules.
Humans ; Breast Neoplasms/mortality* ; Retrospective Studies ; Female ; Propensity Score ; Middle Aged ; Adult ; Prognosis ; Disease-Free Survival ; Kaplan-Meier Estimate ; Aged ; Proportional Hazards Models ; Complex Mixtures/therapeutic use* ; Drugs, Chinese Herbal/therapeutic use* ; Trametes

BACKGROUND: The level of measurable residual disease (MRD) before and after transplantation is related to inferior transplant outcomes, and post-hematopoietic stem cell transplantation measurable residual disease (post-HSCT MRD) has higher prognostic value in determining risk than pre-hematopoietic stem cell transplantation measurable residual disease (pre-HSCT MRD). However, only a few work has been devoted to the risk factors for positive post-HSCT MRD in patients with acute lymphoblastic leukemia (ALL). This study evaluated the risk factors for post-HSCT MRD positivity in patients with ALL who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT). METHODS: A total of 1683 ALL patients from Peking University People's Hospital between January 2009 and December 2019 were enrolled to evaluate the cumulative incidence of post-HSCT MRD. Cox proportional hazard regression models were built for time-to-event outcomes. Multivariable analysis was performed to determine independent influencing factors from the univariable analysis. RESULTS: Both in total patients and in T-cell ALL or B-cell ALL, pediatric or adult, human leukocyte antigen-matched sibling donor transplantation or haploidentical SCT subgroups, positive pre-HSCT MRD was a risk factor for post-HSCT MRD positivity ( P  <0.001 for all). Disease status (complete remission 1 [CR1] vs . ≥CR2) was also a risk factor for post-HSCT MRD positivity in all patients and in the B cell-ALL, pediatric, or haploidentical SCT subgroups ( P  = 0.027; P  = 0.003; P  = 0.035; P  = 0.003, respectively). A risk score for post-HSCT MRD positivity was developed using the variables pre-HSCT MRD and disease status. The cumulative incidence of post-HSCT MRD positivity was 12.3%, 25.1%, and 38.8% for subjects with scores of 0, 1, and 2-3, respectively ( P  <0.001). Multivariable analysis confirmed the association of the risk score with the cumulative incidence of post-HSCT MRD positivity and relapse as well as leukemia-free survival and overall survival. CONCLUSION Our results indicated that positive pre-MRD and disease status were two independent risk factors for post-HSCT MRD positivity in patients with ALL who underwent allo-HSCT.
Humans ; Precursor Cell Lymphoblastic Leukemia-Lymphoma/pathology* ; Neoplasm, Residual ; Hematopoietic Stem Cell Transplantation/methods* ; Male ; Female ; Risk Factors ; Adolescent ; Adult ; Child ; Child, Preschool ; Young Adult ; Middle Aged ; Infant ; Transplantation, Homologous ; Proportional Hazards Models ; Retrospective Studies