Healthcare decision-makers are constantly challenged by growing healthcare needs in tandem with rising healthcare costs. Disinvesting in technologies and practices that are "low in value" is one strategy to re-allocate limited resources to the most effective, safe and cost-effective technologies. We put forward a health technology reassessment framework and examined the opportunities and challenges on technology disinvestment in Singapore and deliberated on possible solutions. We coordinated and supported a disinvestment programme in 2 hospitals, 1 specialist centre and 9 primary care institutions in the public healthcare sector. The key processes were identifying, prioritising and assessing low-value health technologies and practices, disseminating and implementing disinvestment recommendations, and post-implementation evaluation. Through case studies, we explored the barriers and enablers to the success of the programme. One of the barriers to disinvestment included difficulty in demonstrating a lack of benefit of in-use technologies from published studies. Differing viewpoint and priority might preclude a healthcare leader's support in such initiatives and that posed an unsurmountable hurdle. On the other hand, engaging the stakeholder throughout the evidence review process and striking a balance between rigour and timeliness of review were likely to assure success. Lastly, monitoring the impact on resources and patient outcomes can be diverse and methods need to be developed. Understanding barriers and enablers in health technology disinvestment can translate into improved opportunities for eliminating and minimising resource wastage.

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

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

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

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

INTRODUCTIONThis study aims to determine the association of geriatric syndromes and depressed mood among respondents with diabetes in a lower income community; and their association with self-management, lifestyle behaviour, and healthcare utilisation. This paper focuses primarily on the 114 respondents with diabetes aged 50+ to inform policy formulation at the community level.

MATERIALS AND METHODSA pilot community health assessment was conducted in 4 blocks of 1- and 2-room apartments in Toa Payoh district from July to November 2009. Using a standard questionnaire, interviewers conducted face-to-face interviews with household members on chronic diseases, geriatric syndromes and health-related behaviour. Data were analysed using SPSSv15.

RESULTSA total of 795 respondents were assessed with a response rate of 61.8%. Of 515 (64.8%) aged 50+ analysed in this study, 22.1% reported having diabetes, of whom 31.6% reported being depressed. Respondents with diabetes who reported being depressed had a higher prevalence of geriatric syndromes compared with those non-depressed; i.e. functional decline (30.6% vs 5.1%, P <0.001); falls (33.3% vs 10.3%, P = 0.003); stumbling (30.6% vs 10.3%, P = 0.007); urinary incontinence (33.3% vs 5.1%, P <0.001), progressive forgetfulness (27.8% vs 6.4%, P = 0.002) and poor eyesight (22.2% vs 6.4%, P = 0.014). They were less likely to comply with medications (86.1% vs 97.3%, P = 0.026) and performed exercise (13.9% vs 53.8%, P <0.001). More had hospital admissions (13.9% vs 7.7%); and they had more outpatient visits per person (2.4 visits vs 0.9 visits, P = 0.03) at Specialist Outpatient Clinics.

CONCLUSIONGeriatric syndromes were associated with the presence of depressed mood among persons with diabetes in the lower income group. As those with depressed mood had more unfavourable self-management and lifestyle behaviour, and utilise higher healthcare services, diabetes management must take these findings into consideration.

Activities of Daily Living ; Aged ; Depression ; epidemiology ; Diabetes Mellitus ; drug therapy ; psychology ; Disease Management ; Female ; Health Behavior ; Health Promotion ; Health Services ; utilization ; Humans ; Interviews as Topic ; Life Style ; Male ; Middle Aged ; Patient Acceptance of Health Care ; Poverty ; Singapore ; epidemiology ; Surveys and Questionnaires

INTRODUCTIONThis study determines the extent of, and factors associated with, delayed discharges for stroke patients from inpatient rehabilitation.

MATERIALS AND METHODSA retrospective cohort study utilising medical notes review was conducted at an inpatient rehabilitation centre in Singapore. Acute stroke patients (n = 487) admitted between March 2005 and December 2006 were studied. The primary measure was delayed discharge defined as an extension in inpatient stay beyond the planned duration. Factors associated with delays in discharge were categorised as individual, caregiver, medical and organisational.

RESULTSThere were a total of 172 delayed discharges (35.6%). The mean [standard deviation (SD)] length of stay was 40.5 days (SD, 19.5 days) and 25.8 days (SD, 11.4 days) for patients with delayed and prompt discharges, respectively. Mean extension of stay was 9.7 days (SD, 13.8 days). Caregiver-related reasons were cited for 79.7% of the delays whereas organisational factors (awaiting nursing home placement, investigations or specialist appointments) accounted for 17.4%. Four factors were found to be independently associated with delayed discharge: discharge to the care of foreign domestic helper, nursing home placement, lower admission Functional Independence Measure (FIM) motor score and discharge planning process.

CONCLUSIONSOur study suggests that caregiver and organisational factors were main contributors of delayed discharge. Targeted caregiver training and the provision of post-discharge support may improve the confidence of caregivers of patients with greater motor disability. The use of structured discharge planning programmes may improve the efficiency of the rehabilitation service. To reduce delays, problems with the supply of formal and informal post-discharge care must also be addressed.

Aged ; Cohort Studies ; Female ; Humans ; Male ; Middle Aged ; Patient Discharge ; Rehabilitation Centers ; Retrospective Studies ; Singapore ; Stroke Rehabilitation

INTRODUCTIONThe National Healthcare Group (NHG) launched an enterprise-wide diabetes registry in 2007. We describe the epidemiology of type 2 diabetes mellitus from 2005 to 2008.

MATERIALS AND METHODSPatients with encounters in NHG from 2005 were identified for inclusion into the Diabetes Registry from existing stand-alone diabetes registries, ICD9CM diagnosis codes, anti-hyperglycaemic medication and laboratory confirmation. Variables extracted for analysis were demographics (age, gender, ethnicity), diabetes-related comorbidities and complications, most recent anti-hyperglycaemic agents dispensed, and the most recent glycated haemoglobin (HbA1C) measurement.

RESULTSThe diabetes registry grew 32% from 129,183 patients in 2005 to 170,513 patients in 2008, making up 12% to 15% of all patients in NHG. About half of the type 2 diabetes patients were aged 45 to 64 years. Females were generally older with a median age of 63 to 64 years vs 59 to 61 years in males. The Indian ethnic group accounted a disproportionately higher 13% of patients. Over 95% of type 2 patients had at least one diabetes-related comorbid condition, and diabetes-related complications were principally renal and cardiovascular complications. The majority (86.2% to 89.2%) of primary care patients were on oral anti-hyperglycaemic agents; however, the rate of insulin treatment increased from 10.8% to 13.8%. HbA1C levels in 2008 improved over that in 2005, with the percentage of patients with good glycaemic control improving with age.

CONCLUSIONThe registry has enabled a baseline assessment of the burden and the care of type 2 diabetes patients in NHG, which will provide critical "evidence" for planning future programmes.

Administration, Oral ; Adult ; Age Distribution ; Aged ; Aged, 80 and over ; Comorbidity ; Diabetes Mellitus, Type 2 ; drug therapy ; epidemiology ; Female ; Humans ; Hypoglycemic Agents ; administration & dosage ; Injections, Intramuscular ; Male ; Middle Aged ; Registries ; Sex Distribution ; 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