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Ng TKS, Wee HN, Ching J, Kovalik JP, Chan AW, Matchar DB. Plasma Acylcarnitines as Metabolic Signatures of Declining Health-Related Quality of Life Measure in Community-Dwelling Older Adults: A Combined Cross-sectional and Longitudinal Pilot Study. J Gerontol A Biol Sci Med Sci 2024; 79:glac114. [PMID: 35605263 DOI: 10.1093/gerona/glac114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Health-related quality of life (HRQoL) measures are predictors of adverse health outcomes in older adults. Studies have demonstrated cross-sectional associations between HRQoL measures and blood-based biochemical markers. Acylcarnitines (ACs) are a class of metabolites generated in the mitochondria and are predictive of multiple geriatric syndromes. Changes in ACs reflect alterations in central carbon metabolic pathways. However, the prospective relationship between plasma ACs and declining HRQoL has not been examined. This study aimed to investigate both cross-sectional and longitudinal associations of baseline ACs with baseline and declining EuroQol-5 Dimension/EuroQol Visual Analogue Scale (EQ-5D/EQ-VAS) in community-dwelling older adults. METHODS One hundred and twenty community-dwelling older adults with EQ-5D/EQ-VAS measurements at baseline and follow-up were included. We quantified ACs at baseline using targeted plasma metabolomics profiling. Multivariate regressions were performed to examine cross-sectional and longitudinal associations between the measures. RESULTS Cross-sectionally, ACs showed no significant associations with either EQ-5D index or EQ-VAS scores. Longitudinally, multiple baseline short-chain ACs were significantly and inversely associated with declining EQ-5D index score, explaining up to 8.5% of variance in the decline. CONCLUSIONS Within a cohort of community-dwelling older adults who had high HRQoL at baseline, we showed that higher levels of short-chain ACs are longitudinally associated with declining HRQoL. These findings reveal a novel association between central carbon metabolic pathways and declining HRQoL. Notably, dysregulation in mitochondrial central carbon metabolism could be detected prior to clinically important decline in HRQoL, providing the first evidence of objective biomarkers as novel predictors to monitor HRQoL in nonpharmacological interventions and epidemiology.
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Affiliation(s)
- Ted Kheng Siang Ng
- Edson College of Nursing and Health Innovation, Arizona State University, USA
| | - Hai Ning Wee
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
| | - Jianhong Ching
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | - Jean-Paul Kovalik
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
| | - Angelique W Chan
- Program in Health Services and Systems Research, Duke-National University of Singapore Medical School, Singapore
- Department of Sociology, Faculty of Arts and Social Sciences, National University of Singapore, Singapore
- Center for Aging, Research and Education, Duke-National University of Singapore Medical School, Singapore
| | - David Bruce Matchar
- Program in Health Services and Systems Research, Duke-National University of Singapore Medical School, Singapore
- Center for Aging, Research and Education, Duke-National University of Singapore Medical School, Singapore
- Department of Medicine (General Internal Medicine), Duke University School of Medicine, USA
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Chen W, Wong NCB, Wang Y, Zemlyanska Y, Butani D, Virabhak S, Matchar DB, Prapinvanich T, Teerawattananon Y. Mapping the value for money of precision medicine: a systematic literature review and meta-analysis. Front Public Health 2023; 11:1151504. [PMID: 38074712 PMCID: PMC10704154 DOI: 10.3389/fpubh.2023.1151504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 10/04/2023] [Indexed: 12/18/2023] Open
Abstract
Objective This study aimed to quantify heterogeneity in the value for money of precision medicine (PM) by application types across contexts and conditions and to quantify sources of heterogeneity to areas of particular promises or concerns as the field of PM moves forward. Methods A systemic search was performed in Embase, Medline, EconLit, and CRD databases for studies published between 2011 and 2021 on cost-effectiveness analysis (CEA) of PM interventions. Based on a willingness-to-pay threshold of one-time GDP per capita of each study country, the net monetary benefit (NMB) of PM was pooled using random-effects meta-analyses. Sources of heterogeneity and study biases were examined using random-effects meta-regressions, jackknife sensitivity analysis, and the biases in economic studies checklist. Results Among the 275 unique CEAs of PM, publicly sponsored studies found neither genetic testing nor gene therapy cost-effective in general, which was contradictory to studies funded by commercial entities and early stage evaluations. Evidence of PM being cost-effective was concentrated in a genetic test for screening, diagnosis, or as companion diagnostics (pooled NMBs, $48,152, $8,869, $5,693, p < 0.001), in the form of multigene panel testing (pooled NMBs = $31,026, p < 0.001), which only applied to a few disease areas such as cancer and high-income countries. Incremental effectiveness was an essential value driver for varied genetic tests but not gene therapy. Conclusion Precision medicine's value for money across application types and contexts was difficult to conclude from published studies, which might be subject to systematic bias. The conducting and reporting of CEA of PM should be locally based and standardized for meaningful comparisons.
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Affiliation(s)
- Wenjia Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Nigel Chong Boon Wong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Yi Wang
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Yaroslava Zemlyanska
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Dimple Butani
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Bangkok, Thailand
| | - Suchin Virabhak
- Precision Health Research, Singapore (PRECISE), Singapore, Singapore
| | - David Bruce Matchar
- Precision Health Research, Singapore (PRECISE), Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | | | - Yot Teerawattananon
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Bangkok, Thailand
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Lai WX, Chan AWM, Matchar DB, Ansah JP, Lien CTC, Ismail NH, Wong CH, Xu T, Ho VWT, Tan PJ, Lee JML, Sim RSC, Manap N. Group Model Building on causes and interventions for falls in Singapore: insights from a systems thinking approach. BMC Geriatr 2023; 23:586. [PMID: 37740182 PMCID: PMC10517526 DOI: 10.1186/s12877-023-04294-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 09/08/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Falls in older adults are the result of a complex web of interacting causes, that further results in other physical, emotional, and psychological sequelae. A conceptual framework that represents the reciprocal dynamics of these causal factors can enable clinicians, researchers, and policymakers to clarify goals in falls intervention in older adults. METHODS A Group Model Building (GMB) exercise was conducted with researchers and clinicians from academic units and public healthcare institutes in Singapore. The aim of the exercise was to produce a shared visual representation of the causal structure for falls and engage in discussions on how current and future falls intervention programmes can address falls in the older adults, especially in the Asian context. It was conducted in four steps: 1) Outlining and prioritising desirable patient outcomes, 2) Conceptual model building, 3) Identifying key intervention elements of effective falls intervention programmes, 4) Mapping of interventions to outcomes. This causal loop diagram (CLD) was then used to generate insights into the current understanding of falls causal relationships, current efforts in falls intervention in Singapore, and used to identify gaps in falls research that could be further advanced in future intervention studies. RESULTS Four patient outcomes were identified by the group as key in falls intervention: 1) Falls, 2) Injurious falls, 3) Fear of falling, and 4) Restricted mobility and life space. A CLD of the reciprocal relationships between risk factors and these outcomes are represented in four sub-models: 1) Fear of falling, 2) Injuries associated with falls, 3) Caregiver overprotectiveness, 4) Post-traumatic stress disorder and psychological resilience. Through this GMB exercise, the group gained the following insights: (1) Psychological sequelae of falls is an important falls intervention outcome. (2) The effects of family overprotectiveness, psychological resilience, and PTSD in exacerbating the consequences of falls are not well understood. (3) There is a need to develop multi-component falls interventions to address the multitude of falls and falls related sequelae. CONCLUSION This work illustrates the potential of GMB to promote shared understanding of complex healthcare problems and to provide a roadmap for the development of more effective preventive actions.
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Affiliation(s)
- Wei Xuan Lai
- Duke-NUS Medical School, Programme in Health Services and Systems Research, 8 College Road, Singapore, 169857, Singapore.
| | | | - David Bruce Matchar
- Duke-NUS Medical School, Programme in Health Services and Systems Research, 8 College Road, Singapore, 169857, Singapore
- Department of Medicine, Duke University, Durham, NC, USA
- Singapore-ETH Centre, Future Health Technologies Programme, CREATE Tower, Singapore, Singapore
| | - John Pastor Ansah
- Center for Community Health Integration, Case Western Reserve University, Cleveland, OH, USA
| | | | - Noor Hafizah Ismail
- Department of Continuing and Community Care, Tan Tock Seng Hospital, Singapore, Singapore
- Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chek Hooi Wong
- Geriatric Education and Research Institute, Singapore, Singapore
| | - Tianma Xu
- Health & Social Sciences Cluster, Singapore Institute of Technology, Singapore, Singapore
| | - Vanda Wen Teng Ho
- Department of Medicine, National University Hospital, Singapore, Singapore
| | - Pey June Tan
- Ageing and Age-Associated Disorders Research Group, Health and Translational Medicine Cluster, University of Malaya, Kuala Lumpur, Malaysia
| | - June May Ling Lee
- Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore, Singapore
| | - Rita Siew Choo Sim
- Duke-NUS Medical School, Programme in Health Services and Systems Research, 8 College Road, Singapore, 169857, Singapore
| | - Normala Manap
- Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore, Singapore
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Chen W, Wang Y, Zemlyanska Y, Butani D, Wong NCB, Virabhak S, Matchar DB, Teerawattananon Y. Evaluating the Value for Money of Precision Medicine from Early Cycle to Market Access: A Comprehensive Review of Approaches and Challenges. Value Health 2023; 26:1425-1434. [PMID: 37187236 DOI: 10.1016/j.jval.2023.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 04/05/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES This study aimed to perform a comprehensive review of modeling approaches and methodological and policy challenges in the economic evaluation (EE) of precision medicine (PM) across clinical stages. METHODS First, a systematic review was performed to assess the approaches of EEs in the past 10 years. Next, a targeted review of methodological articles was conducted for methodological and policy challenges in performing EEs of PM. All findings were synthesized into a structured framework that focused on patient population, Intervention, Comparator, Outcome, Time, Equity and ethics, Adaptability and Modeling aspects, named the "PICOTEAM" framework. Finally, a stakeholder consultation was conducted to understand the major determinants of decision making in PM investment. RESULTS In 39 methodological articles, we identified major challenges to the EE of PM. These challenges include that PM applications involve complex and evolving clinical decision space, that clinical evidence is sparse because of small subgroups and complex pathways in PM settings, a one-time PM application may have lifetime or intergenerational impacts but long-term evidence is often unavailable, and that equity and ethics concerns are exceptional. In 275 EEs of PM, current approaches did not sufficiently capture the value of PM compared with targeted therapies, nor did they differentiate Early EEs from Conventional EEs. Finally, policy makers perceived the budget impact, cost savings, and cost-effectiveness of PM as the most important determinants in decision making. CONCLUSIONS There is an urgent need to modify existing guidelines or develop a new reference case that fits into the new healthcare paradigm of PM to guide decision making in research and development and market access.
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Affiliation(s)
- Wenjia Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
| | - Yi Wang
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Yaroslava Zemlyanska
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Dimple Butani
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Thailand
| | | | | | - David Bruce Matchar
- Precision Health Research (PRECISE), Singapore; Health Services and Systems Research, Duke-NUS Medical School, Singapore; Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Yot Teerawattananon
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Thailand
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Teo KW, Hu Y, Chew KT, Pek WY, Chua HC, Matchar DB, Ng YF. Health System Transformation Playbook and Unified Care Model: an integrated design, systems & complexity thinking approach to health system transformation. Front Health Serv 2023; 3:1157038. [PMID: 37600927 PMCID: PMC10433688 DOI: 10.3389/frhs.2023.1157038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/27/2023] [Indexed: 08/22/2023]
Abstract
Health system transformation is a complex journey that often results in unintended consequences. Existing methods to drive health system transformation have intrinsic limitations which impede successful implementation in local contexts. The Health System Transformation Playbook is a design-, systems-, and complexity-thinking enabled methodology to systematically design, prioritize and test health system and services transformation actions, anchored on iterative story telling, model building and pathfinding processes that tackles the scale of socially and technologically complex adaptive systems through time. The Unified Care Model and its associated cascade of models are examples of ongoing application of Health System Transformation Playbook in a regional population health system in Singapore. Use of Health System Transformation Playbook enables stewards of health systems to gain a more systematic and coherent understanding of health systems and services planning and organization development, to accelerate transformation towards people-centered, integrated and value-driven health systems.
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Affiliation(s)
- Ken Wah Teo
- Corporate Development, Khoo Teck Puat Hospital, Yishun Health, National Healthcare Group, Singapore, Singapore
| | - Yun Hu
- Corporate Development, Khoo Teck Puat Hospital, Yishun Health, National Healthcare Group, Singapore, Singapore
| | - Kwee Tiang Chew
- Hospital Administration, Khoo Teck Puat Hospital, Yishun Health, National Healthcare Group, Singapore, Singapore
| | - Wee Yang Pek
- Hospital Administration, Khoo Teck Puat Hospital, Yishun Health, National Healthcare Group, Singapore, Singapore
| | - Hong Choon Chua
- CEO’s Office, Khoo Teck Puat Hospital, Yishun Health, National Healthcare Group, Singapore, Singapore
| | - David Bruce Matchar
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Yeuk Fan Ng
- Corporate Development, Khoo Teck Puat Hospital, Yishun Health, National Healthcare Group, Singapore, Singapore
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
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Foo CD, Chia HX, Teo KW, Farwin A, Hashim J, Choon-Huat Koh G, Matchar DB, Legido-Quigley H, Yap JC. Healthier SG: Singapore's multi-year strategy to transform primary healthcare. Lancet Reg Health West Pac 2023; 37:100861. [PMID: 37529631 PMCID: PMC10388720 DOI: 10.1016/j.lanwpc.2023.100861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/27/2023] [Accepted: 07/12/2023] [Indexed: 08/03/2023]
Affiliation(s)
- Chuan De Foo
- International Working Group for Health Systems Strengthening, Western Pacific Region, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Hui Xiang Chia
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Ken Wah Teo
- Yishun Health, National Healthcare Group, Singapore
| | - Aysha Farwin
- International Working Group for Health Systems Strengthening, Western Pacific Region, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Jumana Hashim
- International Working Group for Health Systems Strengthening, Western Pacific Region, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Gerald Choon-Huat Koh
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - David Bruce Matchar
- Duke-NUS Graduate Medical School, Singapore
- Duke University Medical Center (General Medicine and Pathology), Durham, NC, USA
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
- The George Institute for Global Health and Imperial College London, London, UK
| | - Jason C.H. Yap
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
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Ansah JP, Chia AWY, Koh VJW, Lai WX, Koh JSB, Goh KS, Yeo W, Howe TS, Seow DCC, Mamun K, Balasubramanian D, Varman SD, Yeo AKS, Elamin A, Chan AWM, Matchar DB. Systems modelling as an approach for eliciting the mechanisms for hip fracture recovery among older adults in a participatory stakeholder engagement setting. Front Rehabil Sci 2023; 4:1184484. [PMID: 37424878 PMCID: PMC10327561 DOI: 10.3389/fresc.2023.1184484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023]
Abstract
Introduction Due to an aging population, the rising prevalence and incidence of hip fractures and the associated health and economic burden present a challenge to healthcare systems worldwide. Studies have shown that a complex interplay of physiological, psychological, and social factors often affects the recovery trajectories of older adults with hip fractures, often complicating the recovery process. Methods This research aims to actively engage stakeholders (including doctors, physiotherapists, hip fracture patients, and caregivers) using the systems modeling methodology of Group Model Building (GMB) to elicit the factors that promote or inhibit hip fracture recovery, incorporating a feedback perspective to inform system-wide interventions. Hip fracture stakeholder engagement was facilitated through the Group Model Building approach in a two-half-day workshop of 25 stakeholders. This approach combined different techniques to develop a comprehensive qualitative whole-system view model of the factors that promote or inhibit hip fracture recovery. Results A conceptual, qualitative model of the dynamics of hip fracture recovery was developed that draws on stakeholders' personal experiences through a moderated interaction. Stakeholders identified four domains (i.e., expectation formation, rehabilitation, affordability/availability, and resilience building) that play a significant role in the hip fracture recovery journey.. Discussion The insight that recovery of loss of function due to hip fracture is attributed to (a) the recognition of a gap between pre-fracture physical function and current physical function; and (b) the marshaling of psychological resilience to respond promptly to a physical functional loss via uptake of rehabilitation services is supported by findings and has several policy implications.
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Affiliation(s)
- John Pastor Ansah
- Center for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, United States
- Programme in Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Aloysius Wei-Yan Chia
- Programme in Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Vanessa Jean Wen Koh
- Programme in Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Centre for Ageing Research and Education (CARE), Duke-NUS Medical School, Singapore, Singapore
| | - Wei Xuan Lai
- Programme in Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Joyce Suang Bee Koh
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | - Kiat Sern Goh
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - William Yeo
- Orthopaedic Diagnostics Centre, Singapore General Hospital, Singapore, Singapore
| | - Tet Sen Howe
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | | | - Kaysar Mamun
- Department of Geriatric Medicine, Singapore General Hospital, Singapore, Singapore
| | | | | | - Andy Kuei Siong Yeo
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore, Singapore
| | - Amal Elamin
- School of Human Sciences, Faculty of Education, Health and Human Sciences, University of Greenwich, London, United Kingdom
| | - Angelique Wei-Ming Chan
- Programme in Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Centre for Ageing Research and Education (CARE), Duke-NUS Medical School, Singapore, Singapore
| | - David Bruce Matchar
- Programme in Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
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Tan PJ, Ginting ML, Lim ZZB, Balachandar N, Sultana R, Kadir MM, Xu T, Ismail NH, Yap JKY, Wong SF, Yoong J, Matchar DB, Hill K, Wong CH. Pragmatic multicentre stepped-wedge cluster randomised trial to investigate the effectiveness of community-based falls prevention programme for older adults with falls risk in Singapore: a protocol paper. BMJ Open 2023; 13:e072029. [PMID: 37263684 DOI: 10.1136/bmjopen-2023-072029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION Falls are an important public health issue with consequences that include injuries, quality of life reduction and high healthcare costs. Studies show that falls prevention strategies are effective in reducing falls rate among community-dwelling older adults. However, the evaluation for effectiveness was usually done in a controlled setting with homogeneous population, and thus may not be generalisable to a wider population. This study aims to evaluate the impact of community falls prevention programmes with group-based strength and balance exercises, on falls risk and health outcomes for older adults with falls risk in Singapore. METHODS AND ANALYSIS This is a pragmatic closed cohort stepped-wedge cluster randomised trial design study, which involves sequential crossover of clusters from the waitlist control condition to the intervention condition, with the sequence of crossover randomly determined. The intervention will be sequentially rolled out to 12 clusters (a minimum of 5 participants/cluster), over 6 time periods with 8-week intervals in Central and North regions of Singapore. The primary analysis will be conducted under the intention-to-treat principle. A general linear mixed model or generalised estimating equation analysis appropriate for a multilevel longitudinal study incorporating an appropriate error distribution and link function will be used. Markov model will be developed to estimate the incremental cost per quality-adjusted life years and incremental cost per fall prevented from the implementation of falls prevention strategies from a societal perspective. Conditional on there being clinically relevant differences in short-term outcomes, we will implement simulation modelling to project the long-term divergence in trajectories for outcomes and costs using the Markov model. ETHICS AND DISSEMINATION Ethics approval has been obtained. Results will be disseminated in publications and other relevant platforms. TRIAL REGISTRATION NUMBER NCT04788251.
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Affiliation(s)
- Pey June Tan
- Geriatric Education and Research Institute, Singapore
| | | | | | | | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | | | - Tianma Xu
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore
| | - Noor Hafizah Ismail
- Department of Continuing and Community Care, Tan Tock Seng Hospital, Singapore
| | - Joyce Kwee Yong Yap
- Department of Continuing and Community Care, Tan Tock Seng Hospital, Singapore
| | - Sweet Fun Wong
- Population Health & Community Transformation, Khoo Teck Puat Hospital, Singapore
| | - Joanne Yoong
- Center for Economic and Social Research, University of Southern California, Los Angeles, California, USA
- Research for Impact, Singapore
| | | | - Keith Hill
- Rehabilitation Aging and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia
| | - Chek Hooi Wong
- Geriatric Education and Research Institute, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Matchar DB, Lai WX, Kumar A, Ansah JP, Ng YF. A Causal View of the Role and Potential Limitations of Capitation in Promoting Whole Health System Performance. Int J Environ Res Public Health 2023; 20:4581. [PMID: 36901591 PMCID: PMC10002232 DOI: 10.3390/ijerph20054581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 06/18/2023]
Abstract
For several decades, health systems in developed countries have faced rapidly rising healthcare costs without concomitant improvements in health outcomes. Fee for service (FFS) reimbursement mechanisms (RMs), where health systems are paid based on volume, contribute to this trend. In Singapore, the public health service is trying to curb rising healthcare costs by transitioning from a volume-based RM to a capitated payment for a population within a geographical catchment area. To provide insight into the implications of this transition, we developed a causal loop diagram (CLD) to represent a causal hypothesis of the complex relationship between RM and health system performance. The CLD was developed with input from government policymakers, healthcare institution administrators, and healthcare providers. This work highlights that the causal relationships between government, provider organizations, and physicians involve numerous feedback loops that drive the mix of health services. The CLD clarifies that a FFS RM incentivizes high margin services irrespective of their health benefits. While capitation has the potential to mitigate this reinforcing phenomenon, it is not sufficient to promote service value. This suggests the need to establish robust mechanisms to govern common pool resources while minimizing adverse secondary effects.
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Affiliation(s)
- David Bruce Matchar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
- Department of Medicine, Duke University, Durham, NC 27708, USA
| | - Wei Xuan Lai
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Ashish Kumar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
| | - John Pastor Ansah
- Center for Community Health Integration, Case Western Reserve University, Cleveland, OH 44106, USA
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Lam SSW, Fang AHS, Koh MS, Shantakumar S, Yeo SH, Matchar DB, Ong MEH, Poon KMT, Huang L, Harikrishan S, Milea D, Burke D, Webb D, Ragavendran N, Tan NC, Loo CM. Development of a real-world database for asthma and COPD: The SingHealth-Duke-NUS-GSK COPD and Asthma Real-World Evidence (SDG-CARE) collaboration. BMC Med Inform Decis Mak 2023; 23:4. [PMID: 36624490 PMCID: PMC9830781 DOI: 10.1186/s12911-022-02071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 11/25/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE The SingHealth-Duke-GlaxoSmithKline COPD and Asthma Real-world Evidence (SDG-CARE) collaboration was formed to accelerate the use of Singaporean real-world evidence in research and clinical care. A centerpiece of the collaboration was to develop a near real-time database from clinical and operational data sources to inform healthcare decision making and research studies on asthma and chronic obstructive pulmonary disease (COPD). METHODS Our multidisciplinary team, including clinicians, epidemiologists, data scientists, medical informaticians and IT engineers, adopted the hybrid waterfall-agile project management methodology to develop the SingHealth COPD and Asthma Data Mart (SCDM). The SCDM was developed within the organizational data warehouse. It pulls and maps data from various information systems using extract, transform and load (ETL) pipelines. Robust user testing and data verification was also performed to ensure that the business requirements were met and that the ETL pipelines were valid. RESULTS The SCDM includes 199 data elements relevant to asthma and COPD. Data verification was performed and found the SCDM to be reliable. As of December 31, 2019, the SCDM contained 36,407 unique patients with asthma and COPD across the spectrum from primary to tertiary care in our healthcare system. The database updates weekly to add new data of existing patients and to include new patients who fulfil the inclusion criteria. CONCLUSIONS The SCDM was systematically developed and tested to support the use RWD for clinical and health services research in asthma and COPD. This can serve as a platform to provide research and operational insights to improve the care delivered to our patients.
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Affiliation(s)
- Sean Shao Wei Lam
- grid.428397.30000 0004 0385 0924Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore ,grid.453420.40000 0004 0469 9402Health Services Research Centre, Singapore Health Services, 20 College Road, The Academia – Discovery Tower Level 6, Singapore, 169856 Singapore ,grid.512024.00000 0004 8513 1236Health Services Research Institute, SingHealth Duke NUS Academic Medical Centre, Singapore, Singapore ,grid.412634.60000 0001 0697 8112Lee Kong Chian School of Business, Singapore Management University, Singapore, Singapore
| | - Andrew Hao Sen Fang
- grid.453420.40000 0004 0469 9402SingHealth Polyclinics, SingHealth, Singapore, Singapore
| | - Mariko Siyue Koh
- grid.163555.10000 0000 9486 5048Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore ,grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Singapore, Singapore
| | - Sumitra Shantakumar
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Singapore, Singapore ,GlaxoSmithKline, Singapore, Singapore
| | | | - David Bruce Matchar
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Singapore, Singapore ,grid.26009.3d0000 0004 1936 7961Department of Internal Medicine (General Internal Medicine), Duke University Medical School, Durham, NC USA ,grid.163555.10000 0000 9486 5048Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- grid.428397.30000 0004 0385 0924Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore ,grid.453420.40000 0004 0469 9402Health Services Research Centre, Singapore Health Services, 20 College Road, The Academia – Discovery Tower Level 6, Singapore, 169856 Singapore ,grid.512024.00000 0004 8513 1236Health Services Research Institute, SingHealth Duke NUS Academic Medical Centre, Singapore, Singapore ,grid.163555.10000 0000 9486 5048Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Liming Huang
- Integrated Health Information Systems, Singapore, Singapore
| | - Sudha Harikrishan
- grid.453420.40000 0004 0469 9402Health Services Research Centre, Singapore Health Services, 20 College Road, The Academia – Discovery Tower Level 6, Singapore, 169856 Singapore
| | | | - Des Burke
- GlaxoSmithKline, Singapore, Singapore
| | - Dave Webb
- GlaxoSmithKline, Singapore, Singapore
| | - Narayanan Ragavendran
- grid.453420.40000 0004 0469 9402Health Services Research Centre, Singapore Health Services, 20 College Road, The Academia – Discovery Tower Level 6, Singapore, 169856 Singapore ,grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Singapore, Singapore
| | - Ngiap Chuan Tan
- grid.453420.40000 0004 0469 9402SingHealth Polyclinics, SingHealth, Singapore, Singapore ,grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Singapore, Singapore
| | - Chian Min Loo
- grid.163555.10000 0000 9486 5048Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore ,grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Singapore, Singapore
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11
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Surendran S, Foo CD, Matchar DB, Ansah JP, Car J, Koh GCH. Developing integration among stakeholders in the primary care networks of Singapore: a qualitative study. BMC Health Serv Res 2022; 22:782. [PMID: 35706015 PMCID: PMC9198200 DOI: 10.1186/s12913-022-08165-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/09/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Integrating healthcare services across and between the different health system levels can be achieved in a few ways; however, examining the social side of integration is essential and challenging. This paper explores the concept of integration perceived by general practitioners (GPs) and primary care network (PCN) representatives from the regional health systems (RHS) in a GP-RHS PCN and their perceived partnership success. METHODS In this study, we explored three GP-RHS PCNs in Singapore. We used a qualitative research design and, overall, performed 17 semi-structured in-depth interviews with GPs (n = 11) and PCN representatives (n = 6) from the RHS. All interviews were audiotaped and transcribed verbatim. We conducted thematic analysis to inductively identify themes from the data. Singer's conceptual model of integration types was used as guiding principles to derive relevant and salient themes for integration. RESULTS GPs and the RHS perceived the concept of integration through a series of interrelated strategies. Within the normative dimension, a sense of urgency motivated GPs to integrate improvements into their general practice. Participants perceived teamwork and relational climate as appropriate enablers for achieving interpersonal integration in a primary care partnership. While developing a trusted relationship was a perceived success of this partnership across the network, developing camaraderie and gaining knowledge in chronic disease management through the components of functional integration was a perceived success at an individual general practice level. The data also revealed some operational challenges within the structural dimension and some inabilities of the PCN to achieve complete process integration. CONCLUSIONS Our study points to multi-faceted integration, comprising various forms that need to be manifested at all levels of care to achieve coordinated, seamless, and comprehensive care for patients suffering from chronic conditions. The present iteration of the PCN has been shown to offer integration at a level that warrants praise but still requires structural and process integration improvement.
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Affiliation(s)
- Shilpa Surendran
- grid.4280.e0000 0001 2180 6431Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore, Singapore
| | - Chuan De Foo
- grid.4280.e0000 0001 2180 6431Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore, Singapore
| | - David Bruce Matchar
- grid.428397.30000 0004 0385 0924Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - John Pastor Ansah
- grid.428397.30000 0004 0385 0924Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Josip Car
- grid.59025.3b0000 0001 2224 0361Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Gerald Choon Huat Koh
- grid.4280.e0000 0001 2180 6431Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore, Singapore
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Lam SSW, Pourghaderi AR, Abdullah HR, Nguyen FNHL, Siddiqui FJ, Ansah JP, Low JG, Matchar DB, Ong MEH. An Agile Systems Modeling Framework for Bed Resource Planning During COVID-19 Pandemic in Singapore. Front Public Health 2022; 10:714092. [PMID: 35664119 PMCID: PMC9157760 DOI: 10.3389/fpubh.2022.714092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background The COVID-19 pandemic has had a major impact on health systems globally. The sufficiency of hospitals' bed resource is a cornerstone for access to care which can significantly impact the public health outcomes. Objective We describe the development of a dynamic simulation framework to support agile resource planning during the COVID-19 pandemic in Singapore. Materials and Methods The study data were derived from the Singapore General Hospital and public domain sources over the period from 1 January 2020 till 31 May 2020 covering the period when the initial outbreak and surge of COVID-19 cases in Singapore happened. The simulation models and its variants take into consideration the dynamic evolution of the pandemic and the rapidly evolving policies and processes in Singapore. Results The models were calibrated against historical data for the Singapore COVID-19 situation. Several variants of the resource planning model were rapidly developed to adapt to the fast-changing COVID-19 situation in Singapore. Conclusion The agility in adaptable models and robust collaborative management structure enabled the quick deployment of human and capital resources to sustain the high level of health services delivery during the COVID-19 surge.
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Affiliation(s)
- Sean Shao Wei Lam
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Health Services Research Centre, Singapore Health Services, Singapore, Singapore.,SingHealth Duke NUS Academic Medical Centre, Health Services Research Institute, Singapore, Singapore.,Lee Kong Chian School of Business, School of Computing and Information Systems, Singapore Management University, Singapore, Singapore
| | - Ahmad Reza Pourghaderi
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Health Services Research Centre, Singapore Health Services, Singapore, Singapore.,SingHealth Duke NUS Academic Medical Centre, Health Services Research Institute, Singapore, Singapore
| | | | - Francis Ngoc Hoang Long Nguyen
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore.,SingHealth Duke NUS Academic Medical Centre, Health Services Research Institute, Singapore, Singapore
| | | | - John Pastor Ansah
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Residential College 4, National University of Singapore, Singapore, Singapore
| | - Jenny G Low
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore.,Programme in Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore
| | - David Bruce Matchar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Department of Internal Medicine (General Internal Medicine), Duke University Medical School, Durham, NC, United States.,Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Health Services Research Centre, Singapore Health Services, Singapore, Singapore.,SingHealth Duke NUS Academic Medical Centre, Health Services Research Institute, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
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13
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Koh YS, Subramaniam M, Matchar DB, Hong SI, Koh GCH. The associations between caregivers’ psychosocial characteristics and caregivers’ depressive symptoms in stroke settings: a cohort study. BMC Psychol 2022; 10:121. [PMID: 35534900 PMCID: PMC9082830 DOI: 10.1186/s40359-022-00828-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background Studies have found that caregivers can influence stroke survivors’ outcomes, such as mortality. It is thus pertinent to identify significant factors associated with caregivers’ outcomes. The study objective was to examine the associations between caregivers’ psychosocial characteristics and caregivers’ depressive symptoms. Methods The analysis obtained three-month and one-year post-stroke data from the Singapore Stroke Study, which was collected from hospital settings. Caregivers’ depressive symptoms were assessed via the Center for Epidemiologic Studies Depression instrument. Psychosocial characteristics of caregivers included subjective burden (Zarit Burden Interview), quality of care-relationship (a modified 3-item scale from the University of Southern California Longitudinal Study of Three-Generation Families) and expressive social support (an 8-item scale from Pearlin et al.). Mixed effect Tobit regressions were used to examine the associations between these study variables. Results A total of 214 caregivers of stroke patients hospitalized were included in the final analysis. Most caregivers were Chinese women with secondary school education, unemployed and married to the patients. Caregivers' subjective burden was positively associated with their depressive symptoms (Partial regression coefficient: 0.18, 95% CI 0.11–0.24). Quality of care-relationship (Partial regression coefficient: − 0.35, 95% CI − 0.63 to − 0.06) and expressive social support (partial regression coefficient: − 0.28, 95% CI − 0.37 to − 0.19) were negatively associated with caregivers’ depressive symptoms. Caregivers’ depressive symptoms were higher at three-month post-stroke than one-year post-stroke (Partial regression coefficient: − 1.00, 95% CI − 1.80 to − 0.20). Conclusion The study identified subjective burden, quality of care-relationship and expressive social support as significantly associated with caregivers’ depressive symptoms. Caregivers’ communication skills may also play a role in reducing caregivers’ depressive symptoms. Supplementary Information The online version contains supplementary material available at 10.1186/s40359-022-00828-2.
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Abdullah HR, Lam SSW, Ang BY, Pourghaderi A, Nguyen FNHL, Matchar DB, Tan HK, Ong MEH. Resuming elective surgery after COVID-19: A simulation modelling framework for guiding the phased opening of operating rooms. Int J Med Inform 2021; 158:104665. [PMID: 34923449 PMCID: PMC8674476 DOI: 10.1016/j.ijmedinf.2021.104665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To develop a 2-stage discrete events simulation (DES) based framework for the evaluation of elective surgery cancellation strategies and resumption scenarios across multiple operational outcomes. MATERIALS AND METHODS Study data was derived from the data warehouse and domain knowledge on the operational process of the largest tertiary hospital in Singapore. 34,025 unique cases over 43 operating rooms (ORs) and 18 surgical disciplines performed from 1 January 2019 to 31 May 2020 were extracted for the study. A clustering approach was used in stage 1 of the modelling framework to develop the groups of surgeries that followed distinctive postponement patterns. These clusters were then used as inputs for stage 2 where the DES model was used to evaluate alternative phased resumption strategies considering the outcomes of OR utilization, waiting times to surgeries and the time to clear the backlogs. RESULTS The tool enabled us to understand the elective postponement patterns during the COVID-19 partial lockdown period, and evaluate the best phased resumption strategy. Differences in the performance measures were evaluated based on 95% confidence intervals. The results indicate that two of the gradual phased resumption strategies provided lower peak OR and bed utilizations but required a longer time to return to BAU levels. Minimum peak bed demands could also be reduced by approximately 14 beds daily with the gradual resumption strategy, whilst the maximum peak bed demands by approximately 8.2 beds. Peak OR utilization could be reduced to 92% for gradual resumption as compared to a minimum peak of 94.2% with the full resumption strategy. CONCLUSIONS The 2-stage modelling framework coupled with a user-friendly visualization interface were key enablers for understanding the elective surgery postponement patterns during a partial lockdown phase. The DES model enabled the identification and evaluation of optimal phased resumption policies across multiple important operational outcome measures. LAY ABSTRACT During the height of the COVID-19 pandemic, most healthcare systems suspended their non-urgent elective surgery services. This strategy was undertaken as a means to expand surge capacity, through the preservation of structural resources (such as operating theaters, ICU beds, and ventilators), consumables (such as personal protective equipment and medications), and critical healthcare manpower. As a result, some patients had less-essential surgeries postponed due to the pandemic. As the first wave of the pandemic waned, there was an urgent need to quickly develop optimal strategies for the resumption of these surgeries. We developed a 2-stage discrete events simulation (DES) framework based on 34,025 unique cases over 43 operating rooms (ORs) and 18 surgical disciplines performed from 1 January 2019 to 31 May 2020 captured in the Singapore General Hospital (SGH) enterprise data warehouse. The outcomes evaluated were OR utilization, waiting times to surgeries and time to clear the backlogs. A user-friendly visualization interface was developed to enable decision makers to determine the most promising surgery resumption strategy across these outcomes. Hospitals globally can make use of the modelling framework to adapt to their own surgical systems to evaluate strategies for postponement and resumption of elective surgeries.
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Affiliation(s)
- Hairil Rizal Abdullah
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore; Health Services Research Institute, SingHealth Duke NUS Academic Medical Centre, Singapore; Department of Anesthesiology, Singapore General Hospital, Singapore.
| | - Sean Shao Wei Lam
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore; Health Services Research Institute, SingHealth Duke NUS Academic Medical Centre, Singapore; Lee Kong Chian School of Business, Singapore Management University, Singapore; SingHealth Duke-NUS Global Health Institute, Singapore Health Services, Singapore.
| | - Boon Yew Ang
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore; Health Services Research Institute, SingHealth Duke NUS Academic Medical Centre, Singapore.
| | - Ahmadreza Pourghaderi
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore; Health Services Research Institute, SingHealth Duke NUS Academic Medical Centre, Singapore.
| | - Francis Ngoc Hoang Long Nguyen
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore; Health Services Research Institute, SingHealth Duke NUS Academic Medical Centre, Singapore.
| | - David Bruce Matchar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore; Health Services Research Institute, SingHealth Duke NUS Academic Medical Centre, Singapore; Department of Internal Medicine, Duke University, United States; Duke Centre of Clinical Health Policy Research, Duke University, United States.
| | - Hiang Khoon Tan
- Surgery Academic Program, SingHealth Duke NUS Academic Medical Centre, Singapore; Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore; SingHealth Duke-NUS Global Health Institute, Singapore Health Services, Singapore.
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore; Health Services Research Institute, SingHealth Duke NUS Academic Medical Centre, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore.
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15
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Duminy L, Sivapragasam NR, Matchar DB, Visaria A, Ansah JP, Blankart CR, Schoenenberger L. Validation and application of a needs-based segmentation tool for cross-country comparisons. Health Serv Res 2021; 56 Suppl 3:1394-1404. [PMID: 34755337 PMCID: PMC8579203 DOI: 10.1111/1475-6773.13873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/28/2021] [Accepted: 08/09/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To compare countries' health care needs by segmenting populations into a set of needs-based health states. DATA SOURCES We used seven waves of the Survey of Health, Aging and Retirement in Europe (SHARE) panel survey data. STUDY DESIGN We developed the Cross-Country Simple Segmentation Tool (CCSST), a validated clinician-administered instrument for categorizing older individuals by distinct, homogeneous health and related social service needs. Using clinical indicators, self-reported physician diagnosis of chronic disease, and performance-based tests conducted during the survey interview, individuals were assigned to 1-5 global impressions (GI) segments and assessed for having any of the four identifiable complicating factors (CFs). We used Cox proportional hazard models to estimate the risk of mortality by segment. First, we show the segmentation cross-sectionally to assess cross-country differences in the fraction of individuals with different levels of medical needs. Second, we compare the differences in the rate at which individuals transition between those levels and death. DATA COLLECTION/EXTRACTION METHODS We segmented 270,208 observations (from Austria, Belgium, Czech Republic, Denmark, France, Germany, Greece, Israel, Italy, the Netherlands, Poland, Spain, Sweden, and Switzerland) from 96,396 individuals into GI and CF categories. PRINCIPAL FINDINGS The CCSST is a valid tool for segmenting populations into needs-based states, showing Switzerland with the lowest fraction of individuals in high medical needs segments, followed by Denmark and Sweden, and Poland with the highest fraction, followed by Italy and Israel. Comparing hazard ratios of transitioning between health states may help identify country-specific areas for analysis of ecological and cultural risk factors. CONCLUSIONS The CCSST is an innovative tool for aggregate cross-country comparisons of both health needs and transitions between them. A cross-country comparison gives policy makers an effective means of comparing national health system performance and provides targeted guidance on how to identify strategies for curbing the rise of high-need, high-cost patients.
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Affiliation(s)
- Lize Duminy
- Institute for Health Policy and Health EconomicsBern University of Applied SciencesBernSwitzerland
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
| | - Nirmali Ruth Sivapragasam
- Program in Health Services and Systems Research ServiceDuke‐NUS Medical School SingaporeSingaporeSingapore
| | - David Bruce Matchar
- Program in Health Services and Systems Research ServiceDuke‐NUS Medical School SingaporeSingaporeSingapore
- Duke University Medical CenterDuke UniversityDurhamNorth CarolinaUSA
| | - Abhijit Visaria
- Centre for Ageing Research and EducationDuke‐NUS Medical School SingaporeSingaporeSingapore
| | - John Pastor Ansah
- Program in Health Services and Systems Research ServiceDuke‐NUS Medical School SingaporeSingaporeSingapore
| | - Carl Rudolf Blankart
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
- KPM Center for Public ManagementUniversity of BernBernSwitzerland
| | - Lukas Schoenenberger
- Institute for Health Policy and Health EconomicsBern University of Applied SciencesBernSwitzerland
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Wong TH, Tan TXZ, Malhotra R, Nadkarni NV, Chua WC, Loo LM, Iau PTC, Ang ASH, Goo JTT, Chan KC, Matchar DB, Seow DCC, Nguyen HV, Ng YS, Chan A, Fook-Chong S, Tang TY, Ong MEH. Health Services Use and Functional Recovery Following Blunt Trauma in Older Persons - A National Multicentre Prospective Cohort Study. J Am Med Dir Assoc 2021; 23:646-653.e1. [PMID: 34848197 DOI: 10.1016/j.jamda.2021.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 10/19/2021] [Accepted: 10/23/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Frailty is associated with morbidity and mortality in older injured patients. However, for older blunt-trauma patients, increased frailty may not manifest in longer length of stay at index admission. We hypothesized that owing to time spent in hospital from readmissions, frailty would be associated with less total time at home in the 1-year postinjury period. DESIGN Prospective, nationwide, multicenter cohort study. SETTING AND PARTICIPANTS All Singaporean residents aged ≥55 years admitted for blunt trauma with an Injury Severity Score (ISS) or New Injury Severity Score (NISS) ≥10 from March 2016 to July 2018. METHODS Frailty (by modified Fried criteria) was assessed at index admission, based on questions on preinjury weight loss, slowness, exhaustion, physical activity, and grip strength at the time of recruitment. Low time at home was defined as >14 hospitalized days within 1 year postinjury. The contribution of planned and unplanned readmission to time at home postinjury was explored. Functional trajectory (by Barthel Index) over 1 year was compared by frailty. RESULTS Of the 218 patients recruited, 125 (57.3%) were male, median age was 72 years, and 48 (22.0%) were frail. On univariate analysis, frailty [relative to nonfrail: odds ratio (OR) 3.45, 95% confidence interval (CI) 1.33-8.97, P = .01] was associated with low time at home. On multivariable analysis, after inclusion of age, gender, ISS, intensive care unit admission, and surgery at index admission, frailty (OR 5.21, 95% CI 1.77-15.34, P < .01) remained significantly associated with low time at home in the 1-year postinjury period. Unplanned readmissions were the main reason for frail participants having low time at home. Frail participants had poorer function in the 1-year postinjury period. CONCLUSIONS AND IMPLICATIONS In the year following blunt trauma, frail older patients experience lower time at home compared to patients who were not frail at baseline. Screening for frailty should be considered in all older blunt-trauma patients, with a view to being prioritized for postdischarge support.
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Affiliation(s)
- Ting-Hway Wong
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore; Department of General Surgery, Singapore General Hospital, Singapore
| | | | - Rahul Malhotra
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | - Nivedita V Nadkarni
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore
| | | | - Lynette Ma Loo
- Department of General Surgery, National University Hospital, Singapore
| | | | | | | | - Kim Chai Chan
- Emergency Medicine Department, Ng Teng Fong General Hospital, Singapore
| | - David Bruce Matchar
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | | | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, Canada, St. John's, Newfoundland, Canada
| | - Yee Sien Ng
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore
| | - Angelique Chan
- Centre for Ageing Research and Education, Duke-NUS Graduate Medical School, Singapore
| | - Stephanie Fook-Chong
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore
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Seow-En I, Chok AY, Matchar DB, Yoon S, Chong DQ, Tan EKW. Long-term quality of life, sexual health and gastrointestinal function following colorectal cancer resection in an Asian cohort. Colorectal Dis 2021; 23:2348-2360. [PMID: 34097342 DOI: 10.1111/codi.15768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/15/2021] [Accepted: 05/31/2021] [Indexed: 01/22/2023]
Abstract
AIM As populations age and cancer management improves, long-term survivorship and quality-of-life (QOL) outcomes are becoming equally important as oncological results. Data from Asian populations are scarce. We aimed to evaluate the sexual health, gastrointestinal function and QOL amongst colorectal cancer survivors in a tertiary referral centre in Singapore. METHOD Adults who had undergone elective curative surgery for non-metastatic colorectal cancer at least 2 years prior were included. Exclusion criteria were cognitive disease, serious postoperative complications or recurrent cancer. Participants were invited to complete the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires EORTC-QLQ-C30 and QLQ-CR29. Using multiple bivariate analysis, r scores were used to examine relationship trends between QOL domains and survivor sociodemographic and disease-specific characteristics. RESULTS From February 2017 to July 2019, 400 responses were recorded. Median age and follow-up duration were 64 years (range 32-90) and 78 months (interquartile range 49-113) respectively. Patients who had Stage III cancer had better overall QOL scores compared to Stage I/II. Rectal (vs. colon) cancer negatively influenced sexual health and gastrointestinal function, but did not appear to affect overall QOL. Amongst our cohort, 57% (n = 129) of men and 43% (n = 75) of women were sexually active. Markers of socioeconomic status, including employment, education and housing type, were found to significantly impact perception of various aspects of QOL. CONCLUSION Knowledge of factors which influence well-being can identify individuals who may benefit from tailored management strategies. Regular patient-doctor contact may play a role in building and maintaining positive perspectives of cancer survivors. Normative data should be obtained from local populations to facilitate future comparative research.
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Affiliation(s)
- Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Singapore City, Singapore
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Singapore City, Singapore
| | - David Bruce Matchar
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore City, Singapore.,Department of Medicine, Duke University Medical School, Durham, NC, USA
| | - Sungwon Yoon
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore City, Singapore
| | - Dawn Qingqing Chong
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Emile Kwong-Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore City, Singapore
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Ng TKS, Matchar DB, Pyrkov TV, Fedichev PO, Chan AWM, Kennedy B. Association between housing type and accelerated biological aging in different sexes: moderating effects of health behaviors. Aging (Albany NY) 2021; 13:20029-20049. [PMID: 34456185 PMCID: PMC8436907 DOI: 10.18632/aging.203447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/10/2021] [Indexed: 11/25/2022]
Abstract
Introduction: Despite associated with multiple geriatric disorders, whether housing type, an indicator of socioeconomic status (SES) and environmental factors, is associated with accelerated biological aging is unknown. Furthermore, although individuals with low-SES have higher body mass index (BMI) and are more likely to smoke, whether BMI and smoking status moderate the association between SES and biological aging is unclear. We examined these questions in urbanized low-SES older community-dwelling adults. Methods: First, we analyzed complete blood count data using the cox proportional hazards model and derived measures for biological age (BA) and biological age acceleration (BAA, the higher the more accelerated aging) (N = 376). Subsequently, BAA was regressed on housing type, controlling for covariates, including four other SES indicators. Interaction terms between housing type and BMI/smoking status were separately added to examine their moderating effects. Total sample and sex-stratified analyses were performed. Results: There were significant differences between men and women in housing type and BAA. Compared to residents in ≥3 room public or private housing, older adults resided in 1–2 room public housing had a higher BAA. Furthermore, BMI attenuated the association between housing type and BAA. In sex-stratified analyses, the main and interaction effects were only significant in women. In men, smoking status instead aggravated the association between housing type and BAA. Conclusion: Controlling for other SES indicators, housing type is an independent socio-environmental determinant of BA and BAA in a low-SES urbanized population. There were also sex differences in the moderating effects of health behaviors on biological aging.
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Affiliation(s)
- Ted Kheng Siang Ng
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, AZ 85004, USA.,National Cheng Kung University, Institute of Behavioral Medicine, College of Medicine, Taiwan
| | - David Bruce Matchar
- Duke-National University of Singapore Medical School, Program in Health Services and Systems Research, Singapore.,Duke University School of Medicine, Department of Medicine (General Internal Medicine), Durham, NC 27710, USA
| | | | - Peter O Fedichev
- GERO PTE. LTD., Singapore.,Moscow Institute of Physics and Technology, Dolgoprudny, Moscow Region 141700, Russia
| | - Angelique Wei-Ming Chan
- Duke-National University of Singapore Medical School, Program in Health Services and Systems Research, Singapore.,Duke-National University of Singapore Medical School, Center for Aging, Research and Education, Singapore.,National University of Singapore, Department of Sociology, Faculty of Arts and Social Sciences, Singapore
| | - Brian Kennedy
- National University of Singapore, Center for Healthy Longevity, Healthy Longevity Program and Department of Biochemistry, Yong Loo Lin School of Medicine, Singapore.,Singapore Institute of Clinical Sciences, A*STAR, Singapore
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19
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Xie F, Ong MEH, Liew JNMH, Tan KBK, Ho AFW, Nadarajan GD, Low LL, Kwan YH, Goldstein BA, Matchar DB, Chakraborty B, Liu N. Development and Assessment of an Interpretable Machine Learning Triage Tool for Estimating Mortality After Emergency Admissions. JAMA Netw Open 2021; 4:e2118467. [PMID: 34448870 PMCID: PMC8397930 DOI: 10.1001/jamanetworkopen.2021.18467] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Triage in the emergency department (ED) is a complex clinical judgment based on the tacit understanding of the patient's likelihood of survival, availability of medical resources, and local practices. Although a scoring tool could be valuable in risk stratification, currently available scores have demonstrated limitations. OBJECTIVES To develop an interpretable machine learning tool based on a parsimonious list of variables available at ED triage; provide a simple, early, and accurate estimate of patients' risk of death; and evaluate the tool's predictive accuracy compared with several established clinical scores. DESIGN, SETTING, AND PARTICIPANTS This single-site, retrospective cohort study assessed all ED patients between January 1, 2009, and December 31, 2016, who were subsequently admitted to a tertiary hospital in Singapore. The Score for Emergency Risk Prediction (SERP) tool was derived using a machine learning framework. To estimate mortality outcomes after emergency admissions, SERP was compared with several triage systems, including Patient Acuity Category Scale, Modified Early Warning Score, National Early Warning Score, Cardiac Arrest Risk Triage, Rapid Acute Physiology Score, and Rapid Emergency Medicine Score. The initial analyses were completed in October 2020, and additional analyses were conducted in May 2021. MAIN OUTCOMES AND MEASURES Three SERP scores, namely SERP-2d, SERP-7d, and SERP-30d, were developed using the primary outcomes of interest of 2-, 7-, and 30-day mortality, respectively. Secondary outcomes included 3-day mortality and inpatient mortality. The SERP's predictive power was measured using the area under the curve in the receiver operating characteristic analysis. RESULTS The study included 224 666 ED episodes in the model training cohort (mean [SD] patient age, 63.60 [16.90] years; 113 426 [50.5%] female), 56 167 episodes in the validation cohort (mean [SD] patient age, 63.58 [16.87] years; 28 427 [50.6%] female), and 42 676 episodes in the testing cohort (mean [SD] patient age, 64.85 [16.80] years; 21 556 [50.5%] female). The mortality rates in the training cohort were 0.8% at 2 days, 2.2% at 7 days, and 5.9% at 30 days. In the testing cohort, the areas under the curve of SERP-30d were 0.821 (95% CI, 0.796-0.847) for 2-day mortality, 0.826 (95% CI, 0.811-0.841) for 7-day mortality, and 0.823 (95% CI, 0.814-0.832) for 30-day mortality and outperformed several benchmark scores. CONCLUSIONS AND RELEVANCE In this retrospective cohort study, SERP had better prediction performance than existing triage scores while maintaining easy implementation and ease of ascertainment in the ED. It has the potential to be widely applied and validated in different circumstances and health care settings.
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Affiliation(s)
- Feng Xie
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
| | - Marcus Eng Hock Ong
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | | | - Andrew Fu Wah Ho
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Lian Leng Low
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
| | - Yu Heng Kwan
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
| | - Benjamin Alan Goldstein
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - David Bruce Matchar
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Duke University Medical Center, Duke University, Durham, North Carolina
| | - Bibhas Chakraborty
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Department of Statistics and Data Science, National University of Singapore, Singapore
| | - Nan Liu
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Health Service Research Centre, Singapore Health Services, Singapore
- Institute of Data Science, National University of Singapore, Singapore
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20
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Foo CD, Surendran S, Tam CH, Ho E, Matchar DB, Car J, Koh GCH. Perceived facilitators and barriers to chronic disease management in primary care networks of Singapore: a qualitative study. BMJ Open 2021; 11:e046010. [PMID: 33947737 PMCID: PMC8098912 DOI: 10.1136/bmjopen-2020-046010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE The increasing chronic disease burden has placed tremendous strain on tertiary healthcare resources in most countries, necessitating a shift in chronic disease management from tertiary to primary care providers. The Primary Care Network (PCN) policy was promulgated as a model of care to organise private general practitioners (GPs) into groups to provide GPs with resources to anchor patients with chronic conditions with them in the community. As PCN is still in its embryonic stages, there is a void in research regarding its ability to empower GPs to manage patients with chronic conditions effectively. This qualitative study aims to explore the facilitators and barriers for the management of patients with chronic conditions by GPs enrolled in PCN. DESIGN We conducted 30 semistructured interviews with GPs enrolled in a PCN followed by a thematic analysis of audio transcripts until data saturation was achieved. SETTING Singapore. RESULTS Our results suggest that PCNs facilitated GPs to more effectively manage patients through (1) provision of ancillary services such as diabetic foot screening, diabetic retinal photography and nurse counselling to permit a 'one-stop-shop', (2) systematic monitoring of process and clinical outcome indicators through a chronic disease registry (CDR) to promote accountability for patients' health outcomes and (3) funding streams for PCNs to hire additional manpower to oversee operations and to reimburse GPs for extended consultations. Barriers include high administrative load in maintaining the CDR due to the lack of a smart electronic clinic management system and financial gradient faced by patients seeking services from private GPs which incur higher out-of-pocket expenses than public primary healthcare institutions. CONCLUSION PCNs demonstrate great promise in empowering enrolled GPs to manage patients with chronic conditions. However, barriers will need to be addressed to ensure the viability of PCNs in managing more patients in the face of an ageing population.
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Affiliation(s)
- Chuan De Foo
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Shilpa Surendran
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Chen Hee Tam
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Elaine Ho
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - David Bruce Matchar
- Internal Medicine, Duke University, Durham, North Carolina, USA
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gerald Choon Huat Koh
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
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21
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Ansah JP, Matchar DB, Shao Wei SL, Low JG, Pourghaderi AR, Siddiqui FJ, Min TLS, Wei-Yan AC, Ong MEH. The effectiveness of public health interventions against COVID-19: Lessons from the Singapore experience. PLoS One 2021; 16:e0248742. [PMID: 33784332 PMCID: PMC8009429 DOI: 10.1371/journal.pone.0248742] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 03/04/2021] [Indexed: 01/12/2023] Open
Abstract
Background In dealing with community spread of COVID-19, two active interventions have been attempted or advocated—containment, and mitigation. Given the extensive impact of COVID-19 globally, there is international interest to learn from best practices that have been shown to work in controlling community spread to inform future outbreaks. This study explores the trajectory of COVID-19 infection in Singapore had the government intervention not focused on containment, but rather on mitigation. In addition, we estimate the actual COVID-19 infection cases in Singapore, given that confirmed cases are publicly available. Methods and findings We developed a COVID-19 infection model, which is a modified SIR model that differentiate between detected (diagnosed) and undetected (undiagnosed) individuals and segments total population into seven health states: susceptible (S), infected asymptomatic undiagnosed (A), infected asymptomatic diagnosed (I), infected symptomatic undiagnosed (U), infected symptomatic diagnosed (E), recovered (R), and dead (D). To account for the infection stages of the asymptomatic and symptomatic infected individuals, the asymptomatic infected individuals were further disaggregated into three infection stages: (a) latent (b) infectious and (c) non-infectious; while the symptomatic infected were disaggregated into two stages: (a) infectious and (b) non-infectious. The simulation result shows that by the end of the current epidemic cycle without considering the possibility of a second wave, under the containment intervention implemented in Singapore, the confirmed number of Singaporeans infected with COVID-19 (diagnosed asymptomatic and symptomatic cases) is projected to be 52,053 (with 95% confidence range of 49,370–54,735) representing 0.87% (0.83%-0.92%) of the total population; while the actual number of Singaporeans infected with COVID-19 (diagnosed and undiagnosed asymptomatic and symptomatic infected cases) is projected to be 86,041 (81,097–90,986), which is 1.65 times the confirmed cases and represents 1.45% (1.36%-1.53%) of the total population. A peak in infected cases is projected to have occurred on around day 125 (27/05/2020) for the confirmed infected cases and around day 115 (17/05/2020) for the actual infected cases. The number of deaths is estimated to be 37 (34–39) among those infected with COVID-19 by the end of the epidemic cycle; consequently, the perceived case fatality rate is projected to be 0.07%, while the actual case fatality rate is estimated to be 0.043%. Importantly, our simulation model results suggest that there about 65% more COVID-19 infection cases in Singapore that have not been captured in the official reported numbers which could be uncovered via a serological study. Compared to the containment intervention, a mitigation intervention would have resulted in early peak infection, and increase both the cumulative confirmed and actual infection cases and deaths. Conclusion Early public health measures in the context of targeted, aggressive containment including swift and effective contact tracing and quarantine, was likely responsible for suppressing the number of COVID-19 infections in Singapore.
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Affiliation(s)
- John P. Ansah
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Residential College 4, National University of Singapore, Singapore, Singapore
- * E-mail:
| | - David Bruce Matchar
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Internal Medicine (General Internal Medicine), Duke University, Singapore, Singapore
- Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Sean Lam Shao Wei
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - Jenny G. Low
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
- Programme in Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore
| | - Ahmad Reza Pourghaderi
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - Fahad Javaid Siddiqui
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Tessa Lui Shi Min
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Aloysius Chia Wei-Yan
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
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22
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Foo CD, Surendran S, Jimenez G, Ansah JP, Matchar DB, Koh GCH. Primary Care Networks and Starfield's 4Cs: A Case for Enhanced Chronic Disease Management. Int J Environ Res Public Health 2021; 18:2926. [PMID: 33809295 PMCID: PMC8001119 DOI: 10.3390/ijerph18062926] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 11/16/2022]
Abstract
The primary care network (PCN) was implemented as a healthcare delivery model which organises private general practitioners (GPs) into groups and furnished with a certain level of resources for chronic disease management. A secondary qualitative analysis was conducted with data from an earlier study exploring facilitators and barriers GPs enrolled in PCN's face in chronic disease management. The objective of this study is to map features of PCN to Starfield's "4Cs" framework. The "4Cs" of primary care-comprehensiveness, first contact access, coordination and continuity-offer high-quality design options for chronic disease management. Interview transcripts of GPs (n = 30) from the original study were purposefully selected. Provision of ancillary services, manpower, a chronic disease registry and extended operating hours of GP practices demonstrated PCN's empowering features that fulfil the "4Cs". On the contrary, operational challenges such as the lack of an integrated electronic medical record and disproportionate GP payment structures limit PCNs from maximising the "4Cs". However, the enabling features mentioned above outweighs the shortfalls in all important aspects of delivering optimal chronic disease care. Therefore, even though PCN is in its early stage of development, it has shown to be well poised to steer GPs towards enhanced chronic disease management.
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Affiliation(s)
- Chuan De Foo
- Department of Health Systems and Behavioural Sciences, Saw Swee Hock School of Public Health, National University Singapore, Singapore 117549, Singapore; (S.S.); (G.C.H.K.)
| | - Shilpa Surendran
- Department of Health Systems and Behavioural Sciences, Saw Swee Hock School of Public Health, National University Singapore, Singapore 117549, Singapore; (S.S.); (G.C.H.K.)
| | - Geronimo Jimenez
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore;
- Department of Public Health and Primary Care, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - John Pastor Ansah
- Health Services and Systems Research, Duke-National University of Singapore Graduate Medical School, Singapore 169857, Singapore; (J.P.A.); (D.B.M.)
| | - David Bruce Matchar
- Health Services and Systems Research, Duke-National University of Singapore Graduate Medical School, Singapore 169857, Singapore; (J.P.A.); (D.B.M.)
- Department of Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, NC 27710, USA
| | - Gerald Choon Huat Koh
- Department of Health Systems and Behavioural Sciences, Saw Swee Hock School of Public Health, National University Singapore, Singapore 117549, Singapore; (S.S.); (G.C.H.K.)
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23
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Surendran S, Foo CD, Tam CH, Ho EQY, Matchar DB, Car J, Koh GCH. The Missed Opportunity of Patient-Centered Medical Homes to Thrive in an Asian Context. Int J Environ Res Public Health 2021; 18:ijerph18041817. [PMID: 33668610 PMCID: PMC7917999 DOI: 10.3390/ijerph18041817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 11/16/2022]
Abstract
In recent years, there is growing interest internationally to implement patient-centered medical homes (PCMHs), and Singapore is no exception. However, studies understanding the influence of contextual policy factors on the implementation of PCMHs are limited. We conducted 10 semi-structured in-depth interviews with general practitioners working in seven out of the nine PCMHs. Audio recordings were transcribed and analyzed by two study team members in NVivo 12 Software using grounded theory techniques. Power dynamics between the stakeholders and lack of shared decision-making among them in selecting the locale of the PCMH and formulating the practice fee and pharmacy structure were the key factors which negatively affected the implementation of PCMHs on a larger scale. Over time, lack of funding to hire dedicated staff to transfer patients and misalignment of various stakeholders’ interest to other right-siting programs also resulted in low number of patients with chronic conditions and revenue. Countries seeking to implement a successful PCMH may benefit from building trust and relationship between stakeholders, engaging in shared decision-making, ongoing cost-efficiency efforts, and formulating a clear delineation of responsibilities between stakeholders. For a healthcare delivery model to succeed in the primary care landscape, policies should be developed keeping mind the realities of primary care practice.
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Affiliation(s)
- Shilpa Surendran
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
- Correspondence:
| | - Chuan De Foo
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
| | - Chen Hee Tam
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
| | - Elaine Qiao Ying Ho
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
| | - David Bruce Matchar
- Health Services and Systems Research, Duke—NUS Medical School, 8 College Road, Singapore 169857, Singapore;
- Department of Medicine (General Internal Medicine), Duke University School of Medicine, 400 Morris Street 3rd Floor, Durham, NC 27701, USA
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Singapore 308232, Singapore;
| | - Gerald Choon Huat Koh
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
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24
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Ansah JP, Ahmad S, Lee LH, Shen Y, Ong MEH, Matchar DB, Schoenenberger L. Modeling Emergency Department crowding: Restoring the balance between demand for and supply of emergency medicine. PLoS One 2021; 16:e0244097. [PMID: 33434228 PMCID: PMC7802975 DOI: 10.1371/journal.pone.0244097] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022] Open
Abstract
Emergency Departments (EDs) worldwide are confronted with rising patient volumes causing significant strains on both Emergency Medicine and entire healthcare systems. Consequently, many EDs are in a situation where the number of patients in the ED is temporarily beyond the capacity for which the ED is designed and resourced to manage-a phenomenon called Emergency Department (ED) crowding. ED crowding can impair the quality of care delivered to patients and lead to longer patient waiting times for ED doctor's consult (time to provider) and admission to the hospital ward. In Singapore, total ED attendance at public hospitals has grown significantly, that is, roughly 5.57% per year between 2005 and 2016 and, therefore, emergency physicians have to cope with patient volumes above the safe workload. The purpose of this study is to create a virtual ED that closely maps the processes of a hospital-based ED in Singapore using system dynamics, that is, a computer simulation method, in order to visualize, simulate, and improve patient flows within the ED. Based on the simulation model (virtual ED), we analyze four policies: (i) co-location of primary care services within the ED, (ii) increase in the capacity of doctors, (iii) a more efficient patient transfer to inpatient hospital wards, and (iv) a combination of policies (i) to (iii). Among the tested policies, the co-location of primary care services has the largest impact on patients' average length of stay (ALOS) in the ED. This implies that decanting non-emergency lower acuity patients from the ED to an adjacent primary care clinic significantly relieves the burden on ED operations. Generally, in Singapore, there is a tendency to strengthen primary care and to educate patients to see their general practitioners first in case of non-life threatening, acute illness.
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Affiliation(s)
- John Pastor Ansah
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore City, Singapore
| | - Salman Ahmad
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore City, Singapore
| | - Lin Hui Lee
- Operations & Performance Management, Singapore General Hospital, Bukit Merah, Singapore City, Singapore
| | - Yuzeng Shen
- Department of Emergency Medicine, Singapore General Hospital, Bukit Merah, Singapore City, Singapore
| | - Marcus Eng Hock Ong
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore City, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Bukit Merah, Singapore City, Singapore
| | - David Bruce Matchar
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore City, Singapore
| | - Lukas Schoenenberger
- Department of Health Professions, Institute of Health Economics and Health Policy, Bern University of Applied Sciences, Bern, Switzerland
- * E-mail:
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25
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Ng TKS, Kovalik JP, Ching J, Chan AW, Matchar DB. Novel metabolomics markers are associated with pre-clinical decline in hand grip strength in community-dwelling older adults. Mech Ageing Dev 2020; 193:111405. [PMID: 33217429 DOI: 10.1016/j.mad.2020.111405] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/26/2020] [Accepted: 11/11/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hand grip strength (HGS) has been proposed as a robust predictor for frailty and sarcopenia. Hence, identifying biomarkers for declining HGS accompanying aging could deepen our understanding of the biological underpinnings, informing pre-emptive intervention. Acylcarnitines (ACs) are metabolites generated by fatty acid metabolism in the mitochondria and are dysregulated in multiple disorders affecting the musculature. However, they have not been comprehensively profiled and examined regarding their utility in predicting variability in declining HGS, longitudinally. Thus, we aimed to: 1) validate previous findings on insignificant cross-sectional association between ACs and HGS, and 2) examine whether baseline ACs were associated with both decline and variability in HGS over 18 months, in community-dwelling older adults. METHODS We included participants who had HGS measured with dynamometer longitudinally (N = 121). We quantified ACs by targeted plasma metabolomics profiling. Multivariable linear regressions were then performed. RESULTS Cross-sectionally, ACs were not significantly associated with HGS. Longitudinally, baseline short-chain dicarboxylic and hydroxylated acylcarnitines (AC-DC/-OH) levels were inversely associated with and significantly explained the variability in 18-month decline in HGS. A specific AC species, the C4-OH, accounted for most of the variance explained. CONCLUSIONS We showed novel biomarkers for declining HGS, furthering molecular understanding and informing nutritional pre-emptive programs.
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Affiliation(s)
- Ted Kheng Siang Ng
- Duke-National University of Singapore Medical School, Center for Aging, Research and Education Singapore.
| | - Jean-Paul Kovalik
- Duke-National University of Singapore Medical School, Cardiovascular and Metabolic Disorders Programme, Singapore
| | - Jianhong Ching
- Duke-National University of Singapore Medical School, Cardiovascular and Metabolic Disorders Programme, Singapore
| | - Angelique W Chan
- Duke-National University of Singapore Medical School, Center for Aging, Research and Education Singapore; Duke-National University of Singapore Medical School, Program in Health Services and Systems Research, Singapore; National University of Singapore, Department of Sociology, Faculty of Arts and Social Sciences, Singapore
| | - David Bruce Matchar
- Duke-National University of Singapore Medical School, Center for Aging, Research and Education Singapore; Duke-National University of Singapore Medical School, Program in Health Services and Systems Research, Singapore; Duke University School of Medicine, Department of Medicine (General Internal Medicine), United States.
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26
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Liu N, Chee ML, Niu C, Pek PP, Siddiqui FJ, Ansah JP, Matchar DB, Lam SSW, Abdullah HR, Chan A, Malhotra R, Graves N, Koh MS, Yoon S, Ho AFW, Ting DSW, Low JGH, Ong MEH. Coronavirus disease 2019 (COVID-19): an evidence map of medical literature. BMC Med Res Methodol 2020; 20:177. [PMID: 32615936 PMCID: PMC7330264 DOI: 10.1186/s12874-020-01059-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/22/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Since the beginning of the COVID-19 outbreak in December 2019, a substantial body of COVID-19 medical literature has been generated. As of June 2020, gaps and longitudinal trends in the COVID-19 medical literature remain unidentified, despite potential benefits for research prioritisation and policy setting in both the COVID-19 pandemic and future large-scale public health crises. METHODS In this paper, we searched PubMed and Embase for medical literature on COVID-19 between 1 January and 24 March 2020. We characterised the growth of the early COVID-19 medical literature using evidence maps and bibliometric analyses to elicit cross-sectional and longitudinal trends and systematically identify gaps. RESULTS The early COVID-19 medical literature originated primarily from Asia and focused mainly on clinical features and diagnosis of the disease. Many areas of potential research remain underexplored, such as mental health, the use of novel technologies and artificial intelligence, pathophysiology of COVID-19 within different body systems, and indirect effects of COVID-19 on the care of non-COVID-19 patients. Few articles involved research collaboration at the international level (24.7%). The median submission-to-publication duration was 8 days (interquartile range: 4-16). CONCLUSIONS Although in its early phase, COVID-19 research has generated a large volume of publications. However, there are still knowledge gaps yet to be filled and areas for improvement for the global research community. Our analysis of early COVID-19 research may be valuable in informing research prioritisation and policy planning both in the current COVID-19 pandemic and similar global health crises.
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Affiliation(s)
- Nan Liu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore.
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore.
| | - Marcel Lucas Chee
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Chenglin Niu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Pin Pin Pek
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - John Pastor Ansah
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - David Bruce Matchar
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Sean Shao Wei Lam
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - Hairil Rizal Abdullah
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Angelique Chan
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Rahul Malhotra
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Nicholas Graves
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Mariko Siyue Koh
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Sungwon Yoon
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Daniel Shu Wei Ting
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Singapore National Eye Centre, Singapore, Singapore
| | - Jenny Guek Hong Low
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
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Tyagi S, Koh GCH, Luo N, Tan KB, Hoenig H, Matchar DB, Yoong J, Chan A, Lee KE, Venketasubramanian N, Menon E, Chan KM, De Silva DA, Yap P, Tan BY, Chew E, Young SH, Ng YS, Tu TM, Ang YH, Kong KH, Singh R, Merchant RA, Chang HM, Yeo TT, Ning C, Cheong A, Tan CS. Dyadic approach to supervised community rehabilitation participation in an Asian setting post-stroke: exploring the role of caregiver and patient characteristics in a prospective cohort study. BMJ Open 2020; 10:e036631. [PMID: 32332008 PMCID: PMC7204848 DOI: 10.1136/bmjopen-2019-036631] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To study the association of caregiver factors and stroke survivor factors with supervised community rehabilitation (SCR) participation over the first 3 months and subsequent 3 to 12 months post-stroke in an Asian setting. DESIGN Prospective cohort study. SETTING Community setting. PARTICIPANTS We recruited stroke survivors and their caregivers into our yearlong cohort. Caregiver and stroke survivor variables were collected over 3-monthly intervals. We performed logistic regression with the outcome variable being SCR participation post-stroke. OUTCOME MEASURES SCR participation over the first 3 months and subsequent 3 to 12 months post-stroke RESULTS: 251 stroke survivor-caregiver dyads were available for the current analysis. The mean age of caregivers was 50.1 years, with the majority being female, married and co-residing with the stroke survivor. There were 61%, 28%, 4% and 7% of spousal, adult-child, sibling and other caregivers. The odds of SCR participation decreased by about 15% for every unit increase in caregiver-reported stroke survivor's disruptive behaviour score (OR: 0.845; 95% CI: 0.769 to 0.929). For every 1-unit increase in the caregiver's positive management strategy score, the odds of using SCR service increased by about 4% (OR: 1.039; 95% CI: 1.011 to 1.068). CONCLUSION We established that SCR participation is jointly determined by both caregiver and stroke survivor factors, with factors varying over the early and late post-stroke period. Our results support the adoption of a dyadic or more inclusive approach for studying the utilisation of community rehabilitation services, giving due consideration to both the stroke survivors and their caregivers. Adopting a stroke survivor-caregiver dyadic approach in practice settings should include promotion of positive care management strategies, comprehensive caregiving training including both physical and behavioural dimensions, active engagement of caregivers in rehabilitation journey and conducting regular caregiver needs assessments in the community.
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Affiliation(s)
- Shilpa Tyagi
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | - Nan Luo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Kelvin Bryan Tan
- Policy Research and Evaluation Division, Ministry of Health, Singapore
| | - Helen Hoenig
- Physical Medicine and Rehabilitation Service, Durham VA Medical Center, Durham, North Carolina, USA
| | - David Bruce Matchar
- Internal Medicine, Duke University, Durham, North Carolina, USA
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Joanne Yoong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Angelique Chan
- Centre for Ageing Research and Education, Duke-NUS Graduate Medical School, Singapore
| | | | | | | | - Kin Ming Chan
- Geriatric Medicine, Mount Alvernia Hospital, Singapore
| | | | - Philip Yap
- Geriatric Centre, Khoo Teck Puat Hospital, Singapore
| | | | - Effie Chew
- Department of Rehabilitation Medicine, National University Hospital, Singapore
| | - Sherry H Young
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore
| | - Yee Sien Ng
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore
| | - Yan Hoon Ang
- Geriatric Medicine, Khoo Teck Puat Hospital, Singapore
| | - Keng He Kong
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore
| | - Rajinder Singh
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore
| | - Reshma A Merchant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hui Meng Chang
- National Neuroscience Institute, Singapore General Hospital Campus, Singapore
| | - Tseng Tsai Yeo
- Department of Neurosurgery, National University Hospital, Singapore
| | - Chou Ning
- Department of Neurosurgery, National University Hospital, Singapore
| | - Angela Cheong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Xu H, Xian Y, Woon FP, Bettger JP, Laskowitz DT, Ng YY, Ong MEH, Matchar DB, De Silva DA. Emergency medical services use and its association with acute ischaemic stroke evaluation and treatment in Singapore. Stroke Vasc Neurol 2020; 5:121-127. [PMID: 32606084 PMCID: PMC7337359 DOI: 10.1136/svn-2019-000277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 03/17/2020] [Accepted: 03/27/2020] [Indexed: 11/25/2022] Open
Abstract
Background Emergency medical services (EMS) is a critical link in the chain of stroke survival. We aimed to assess EMS use for stroke in Singapore, identify characteristics associated with EMS use and the association of EMS use with stroke evaluation and treatment. Methods The Singapore Stroke Registry combines nationwide EMS and public hospital data for stroke cases in Singapore. Multivariate regressions with the generalised estimating equations were performed to examine the association between EMS use and timely stroke evaluation and treatment. Results Of 3555 acute ischaemic patients with symptom onset within 24 hours admitted to all five public hospitals between 2015 and 2016, 68% arrived via EMS. Patients who used EMS were older, were less likely to be female, had higher stroke severity by National Institute of Health Stroke Scale and had a higher prevalence of atrial fibrillation or peripheral arterial disease. Patients transported by EMS were more likely to receive rapid evaluation (door-to-imaging time ≤25 min 34.3% vs 11.1%, OR=2.74 (95% CI 1.40 to 5.38)) and were more likely to receive intravenous tissue plasminogen activator (tPA, 22.8% vs 4.6%, OR=4.61 (95% CI 3.52 to 6.03)). Among patients treated with tPA, patients who arrived via EMS were more likely to receive timely treatment than self-transported patients (door-to-needle time ≤60 min 52.6% vs 29.4%, OR=2.58 (95% CI 1.35 to 4.92)). Conclusions EMS use is associated with timely stroke evaluation and treatment in Singapore. Seamless EMS-Hospital stroke pathways and targeted public campaigns to advocate for appropriate EMS use have the potential to improve acute stroke care.
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Affiliation(s)
- Hanzhang Xu
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, United States .,Duke University School of Nursing, Durham, North Carolina, United States
| | - Ying Xian
- Duke Clinical Research Institute, Durham, North Carolina, United States.,Department of Neurology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Fung Peng Woon
- Department of Neurology, National Neuroscience Institute-Singapore General Hospital Campus, Singapore
| | - Janet Prvu Bettger
- Duke Clinical Research Institute, Durham, North Carolina, United States.,Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, United States
| | - Daniel T Laskowitz
- Duke Clinical Research Institute, Durham, North Carolina, United States.,Department of Neurology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Yih Yng Ng
- HomeTeam, Government of Singapore Ministry of Home Affairs, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | - David Bruce Matchar
- Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore.,Department of Medicine (General Internal Medicine), Duke University School of Medicine, Durham, North Carolina, United States
| | - Deidre Anne De Silva
- Department of Neurology, National Neuroscience Institute-Singapore General Hospital Campus, Singapore
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Ng TKS, Matchar DB, Sultana R, Chan A. Effects of Self-Care for Older PErsons (SCOPE) on Functional and Physiological Measures: A Cluster Randomized Controlled Trial. J Clin Med 2020; 9:jcm9030885. [PMID: 32213860 PMCID: PMC7141527 DOI: 10.3390/jcm9030885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/21/2020] [Accepted: 03/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Population aging poses unprecedented demands on the healthcare system. There is also a scarcity of evidence on self-care intervention to improve objective measures of morbidity and aging-associated functional and physiological measures in a low-income multi-ethnic population setting. Methods: We conducted a cluster randomized controlled trial (ClinicalTrials.gov Identifier: NCT01672177) to examine the effects of the Self-Care for Older PErsons (SCOPE) program. We randomized 14 Senior Activity Centers and randomly selected older adults within these centers. Functional and physiological measurements were performed at baseline, 10-month, and 18-month periods. The primary outcome was a composite of three morbidity-specific measures, which include hemoglobin A1c (HbA1C), peak expiratory flow, and systolic blood pressure. Aging-associated functional and physiological measures were examined as secondary outcomes. Repeated-measure mixed models were employed to examine the effects of SCOPE on these measures. Results: 378 community-dwelling older adults participated in either the treatment (n= 164) or the control arm (n = 214). The primary outcome was not significantly improved. For the secondary outcomes, SCOPE participants demonstrated slower oxygen desaturation at an 18-month period (p = 0.001), improved time to complete the chair-stand test (p < 0.001) at a 10-month period with the effect persisting at the 18-month period (p < 0.001). SCOPE participants also had significantly improved vitamin B12 levels at the 18-month period (p < 0.001), increased hemoglobin concentration (p < 0.001), decreased mean corpuscular volume (p = 0.001), and decreased creatinine (p = 0.002) at the 10-month period. Conclusions: SCOPE did not improve morbidity-specific measures. However, it improved several aging-associated measures implicated in geriatric syndromes. This study highlights the potential of a self-care program in the prevention of geriatric syndromes in community-dwelling older adults, while emphasizing self-management to manage existing morbidities.
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Affiliation(s)
- Ted Kheng Siang Ng
- Center for Aging, Research and Education, Duke-National University of Singapore Medical School, Singapore 169857, Singapore;
| | - David Bruce Matchar
- Program in Health Services and Systems Research, Duke-National University of Singapore Medical School, Singapore 169857, Singapore;
- Department of Medicine (General Internal Medicine), Duke University School of Medicine, Durham, NC 27710, USA
| | - Rehena Sultana
- Center for Quantitative Medicine, Duke-National University of Singapore Medical School, Singapore 169857, Singapore;
| | - Angelique Chan
- Center for Aging, Research and Education, Duke-National University of Singapore Medical School, Singapore 169857, Singapore;
- Program in Health Services and Systems Research, Duke-National University of Singapore Medical School, Singapore 169857, Singapore;
- Department of Sociology, Faculty of Arts and Social Sciences, National University of Singapore, Singapore 117570, Singapore
- Correspondence:
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30
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Chong JL, Low LL, Matchar DB, Malhotra R, Lee KH, Thumboo J, Chan AWM. Do healthcare needs-based population segments predict outcomes among the elderly? Findings from a prospective cohort study in an urbanized low-income community. BMC Geriatr 2020; 20:78. [PMID: 32103728 PMCID: PMC7045405 DOI: 10.1186/s12877-020-1480-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/17/2020] [Indexed: 12/04/2022] Open
Abstract
Background A rapidly ageing population with increasing prevalence of chronic disease presents policymakers the urgent task of tailoring healthcare services to optimally meet changing needs. While healthcare needs-based segmentation is a promising approach to efficiently assessing and responding to healthcare needs at the population level, it is not clear how available schemes perform in the context of community-based surveys administered by non-medically trained personnel. The aim of this prospective cohort, community setting study is to evaluate 4 segmentation schemes in terms of practicality and predictive validity for future health outcomes and service utilization. Methods A cohort was identified from a cross-sectional health and social characteristics survey of Singapore public rental housing residents aged 60 years and above. Baseline survey data was used to assign individuals into segments as defined by 4 predefined population segmentation schemes developed in Singapore, Delaware, Lombardy and North-West London. From electronic data records, mortality, hospital admissions, emergency department visits, and specialist outpatient clinic visits were assessed for 180 days after baseline segment assignment and compared to segment membership for each segmentation scheme. Results Of 1324 residents contacted, 928 agreed to participate in the survey (70% response). All subjects could be assigned an exclusive segment for each segmentation scheme. Individuals in more severe segments tended to have lower quality of life as assessed by the EQ-5D Index for health utility. All population segmentation schemes were observed to exhibit an ability to differentiate different levels of mortality and healthcare utilization. Conclusions It is practical to assign individuals to healthcare needs-based population segments through community surveys by non-medically trained personnel. The resulting segments for all 4 schemes evaluated in this way have an ability to predict health outcomes and utilization over the medium term (180 days), with significant overlap for some segments. Healthcare needs-based segmentation schemes which are designed to guide action hold particular promise for promoting efficient allocation of services to meet the needs of salient population groups. Further evaluation is needed to determine if these schemes also predict responsiveness to interventions to meet needs implied by segment membership.
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Affiliation(s)
- Jia Loon Chong
- Signature Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Lian Leng Low
- Department of Family Medicine and Continuing Care, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore.,SingHealth Duke-NUS Family Medicine Academic Clinical Program, Singapore, Singapore
| | - David Bruce Matchar
- Signature Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore. .,Department of Medicine (General Internal Medicine), Duke University Medical Center, Durham, NC, USA. .,Department of Internal Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore.
| | - Rahul Malhotra
- Signature Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,Centre for Ageing Research and Education, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Kheng Hock Lee
- Department of Family Medicine and Continuing Care, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore.,SingHealth Duke-NUS Family Medicine Academic Clinical Program, Singapore, Singapore
| | - Julian Thumboo
- Signature Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,Department of Rheumatology and Immunology, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Angelique Wei-Ming Chan
- Signature Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,Centre for Ageing Research and Education, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
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Ang YH, Ginting ML, Wong CH, Tew CW, Liu C, Sivapragasam NR, Matchar DB. From Hospital to Home: Impact of Transitional Care on Cost, Hospitalisation and Mortality. Ann Acad Med Singap 2019; 48:333-337. [PMID: 31875471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Yan Hoon Ang
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore
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Xie F, Liu N, Wu SX, Ang Y, Low LL, Ho AFW, Lam SSW, Matchar DB, Ong MEH, Chakraborty B. Novel model for predicting inpatient mortality after emergency admission to hospital in Singapore: retrospective observational study. BMJ Open 2019; 9:e031382. [PMID: 31558458 PMCID: PMC6773418 DOI: 10.1136/bmjopen-2019-031382] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To identify risk factors for inpatient mortality after patients' emergency admission and to create a novel model predicting inpatient mortality risk. DESIGN This was a retrospective observational study using data extracted from electronic health records (EHRs). The data were randomly split into a derivation set and a validation set. The stepwise model selection was employed. We compared our model with one of the current clinical scores, Cardiac Arrest Risk Triage (CART) score. SETTING A single tertiary hospital in Singapore. PARTICIPANTS All adult hospitalised patients, admitted via emergency department (ED) from 1 January 2008 to 31 October 2017 (n=433 187 by admission episodes). MAIN OUTCOME MEASURE The primary outcome of interest was inpatient mortality following this admission episode. The area under the curve (AUC) of the receiver operating characteristic curve of the predictive model with sensitivity and specificity for optimised cut-offs. RESULTS 15 758 (3.64%) of the episodes were observed inpatient mortality. 19 variables were observed as significant predictors and were included in our final regression model. Our predictive model outperformed the CART score in terms of predictive power. The AUC of CART score and our final model was 0.705 (95% CI 0.697 to 0.714) and 0.817 (95% CI 0.810 to 0.824), respectively. CONCLUSION We developed and validated a model for inpatient mortality using EHR data collected in the ED. The performance of our model was more accurate than the CART score. Implementation of our model in the hospital can potentially predict imminent adverse events and institute appropriate clinical management.
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Affiliation(s)
- Feng Xie
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Nan Liu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - Stella Xinzi Wu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Yukai Ang
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Lian Leng Low
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Sean Shao Wei Lam
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| | - David Bruce Matchar
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Duke University Medical Center, Duke University, Durham, North Carolina, USA
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Bibhas Chakraborty
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
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Abstract
BACKGROUND Healthcare needs-based population segmentation is a promising approach for enabling the development and evaluation of integrated healthcare service models that meet healthcare needs. However, healthcare policymakers interested in understanding adult population healthcare needs may not be aware of suitable population segmentation tools available for use in the literature and barring better-known alternatives, may reinvent the wheel by creating and validating their own tools rather than adapting available tools in the literature. Therefore, we undertook a systematic review to identify all available tools which operationalize healthcare need-based population segmentation, to help inform policymakers developing population-level health service programmes. METHODS Using search terms reflecting concepts of population, healthcare need and segmentation, we systematically reviewed and included articles containing healthcare need-based adult population segmentation tools in PubMed, CINAHL and Web of Science databases. We included tools comprising mutually exclusive segments with prognostic value for clinically relevant outcomes. An updated secondary search on the PubMed database was also conducted as the last search was conducted 2 years ago. All identified tools were characterized in terms of segment formulation, segmentation base, whether they received peer-reviewed validation, requirement for comprehensive electronic medical records, proprietary status and number of segments. RESULTS A total of 16 unique tools were identified from systematically reviewing 9970 articles. Peer-reviewed validation studies were found for 9 of these tools. DISCUSSION AND CONCLUSIONS The underlying segmentation basis of most identified tools was found to be conceptually comparable to each other which suggests a broad recognition of archetypical patient overall healthcare need profiles. While many tools operate based on administrative record data, it is noted that healthcare systems without comprehensive electronic medical records would benefit from tools which segment populations through primary data collection. Future work could therefore include development and validation of such primary data collection-based tools. While this study is limited by exclusion of non-English literature, the identified and characterized tools will nonetheless facilitate efforts by policymakers to improve patient-centred care through development and evaluation of services tailored for specific populations segmented by these tools.
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Affiliation(s)
- Jia Loon Chong
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Ka Keat Lim
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - David Bruce Matchar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.
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Mador B, Fuselli P, Choudhary D, Bokhari F, Tanenbaum B, Tze N, Wong TH, Grant I, Sahi S, Tanenbaum B, Figueira S, Knight H, Grant I, Beno S, Moore L, Macpherson A, Laverty C, Watson I, Watson I, Laverty C, Bérubé M, Cowan S, Homer K, Bouderba S, Soltana K, Fransblow L, Fransblow L, Bérubé M, Gonthier C, Bryson A, Bokhari F, Rados A, Courval V, Masales C, Trust MD, Hogan J, Warriner Z, Lalande A, Chung D, Tanenbaun B, Kuper T, Mckee J, Bratu I, Makish A, Versolatto A, Ramagnano S, Mehrnoush V, Kang D, Moore L, Schellenberg M, LeBreton M, Javidan AP, Schwartz G, Doucet J, Cunningham A, Clarke R, Paradis T, Beamish I, Hilsden R, Raizman I, Green R, Green R, Green R, Esmail R, Moon J(J, Cheng V, Brisson A, Beno S, Heck C, Koeck E, Schneider P, Bal C, Ko YM(D, Martinez M, Kim D, Tierney J, Emigh B, Lie J, Tierney J, MacLean A, Milton L, Bradley N, Kim M, White J, Harris I, Tekian A, Babul S, Cowle S, Turcotte K, Dhillon R, Chadha K, Fu CY, Bajan F, Welsh S, Kaminsky M, Dennis A, Starr F, Butler C, Messer T, Poulakidas S, Ramagnano S, Grushka J, Beckett A, Filteau C, Larocque J, Nadkarni N, Chua WC, Loo L, Ang ASH, Iau PTC, Goo JTT, Chan KC, Adam TN, Seow DCC, Ng YS, Malhotra R, Chan AWM, Matchar DB, Van Nguyen H, Ong MEH, Lampron J, Bougie A, Brown C, Patel A, Edwards L, Spitz K, Ramagnano S, Lampron J, Nucete M, Lindsey S, Lampron J, Figueira S, Matar M, Michael D, Rosenfield D, Harvey G, Jessa K, Tardif PA, Mercier E, Berthelot S, Lecky F, Cameron P, Archambault P, Tien H, Beckett A, Nathens A, Luz LTD, Benjamin S, Chisholm A, Benjamin S, Chisholm A, Tien H, Beckett A, Nathens A, Luz LTD, Pasquotti T, Klassen B, Brisson A, Tze N, Fawcett V, Tsang B, Kabaroff A, Verhoeff K, Turner S, Kim M, Widder S, Fung C, Widder S, Kim M, Moore L, Lecky F, Lawrence T, Soltana K, Mansour T, Moore L, Bouderba S, Turgeon A, Krouchev R, Mercier E, Friedman D, Souranis A, Slapcoff L, Friedman D, Fakir MB, Turcotte V, Valiquette MP, Bernard F, Giroux M, Côté MÈ, Gagné A, Dollé S, Gélinas C, Belcaïd A, Truchon C, Moore L, Clément J, Pelletier LP, Ivkov V, Gamble K, Constable L, Haegert J, Bajani F, Fu CY, Welsh S, Kaminsky M, Dennis A, Starr F, Messer T, Butler C, Tatebe L, Poulakidas S, Thauvette D, Engels P, Klassen B, Coates A, De Silva S, Schellenberg M, Biswas S, Inaba K, Cheng V, Warriner Z, Love B, Demetriades D, Schellenberg M, Inaba K, Trust MD, Love B, Cheng V, Strumwasser A, Demetriades D, Joos E, Dawe P, Hameed M, Evans D, Garraway N, Gawaziuk J, Cristall N, Logsetty S, Ramagnano S, Federman N, Murphy P, Parry N, Leeper R, McBeth P, Wachs J, Hamilton D, Ball C, Gillman L, Kirkpatrick A, Dulai S, Falconer C, McLachlin M, Armstrong A, Parry N, Vogt K, Shi Q, Coates A, Engels P, Rice T, Nathens A, Naidu D, Brubacher J, Chan H, Erdelyi S, Kubasiak J, Bokhari F, Kaminsky M, Lauzier F, Tardif PA, Lamontagne F, Chassé M, Stelfox HT, Kortbeek J, Lessard-Bonaventure P, Truchon C, Turgeon A, Cheng V, Inaba K, Foran C, Warriner Z, Trust MD, Clark D, Demetriades D, Levesque K, Lampron J, Nathens A, Tien H, Luz LTD, Jing R, McFarlan A, Liu M, Sander B, Fowler R, Rizoli S, Ferrada P, Murthi S, Nirula R, Edwards S, Cantrell E, Han J, Haase D, Singleton A, Birkas Y, Casola G, Coimbra R, Condron M, Schreiber M, Azarow K, Hamilton N, Long W, Maxwell B, Jafri M, Whitman L, Wilson H, Wong H, Grushka J, Razek T, Fata P, Deckelbaum D, Kawaja K, Beckett A, Razek T, Deckelbaum D, Grushka J, Fata P, Beckett A, Lund M, Leeper R, Conn LG, Strauss R, Haas B, Beckett A, Nathens A, Tien H, Callum J, Luz LTD, Higgins S, Coles J, Erdogan M, Coles J, Higgins S, Erdogan M, Erdogan M, Kureshi N, Fenerty L, Thibault-Halman G, Walling S, Clarke DB, Vis C, Nosworthy S, Razek T, Boulanger N, Deckelbaum D, Grushka J, Fata P, Beckett A, Khwaja K, Schellenberg M, Inaba K, Warriner Z, Trust MD, Matsushima K, Lam L, Demetriades D, Lakha N, Wong H, McLauchlin L, Ashe CS, Logie SA, Lenton-Brym T, Rosenfield D, McDowall D, Wales P, Principi T, Mis J, Kaminsky M, Bokhari F, Rahbar E, Cotton B, Bryan P, MacGillivray S, Thompson G, Wishart I, Hameed M, Joos E, Evans D, Garraway N, Dawe P, Wild J, Widom K, Torres D, Blansfield J, Shabahang M, Dove J, Fluck M, Hameed M, Roux L, Nicol A, Schulenberg L, Fredericks C, Messer T, Starr F, Dennis A, Bokhari F, Kaminsky M, Teixeira P, Coopwood B, Aydelotte J, Cardenas T, Ali S, Brown C, Dawe P, Fredericks C, Matta LD, Messer T, Starr F, Dennis A, Kaminsky M, Bokhari F, Jiang HY, Yoon J, Kim M, Widder S, Hameed M, Wray C, Agarwal A, Harvin J. 2019 Trauma Association of Canada Annual Scientific Meeting Abstracts. Can J Surg 2019; 62:S3-S35. [PMID: 31091053 DOI: 10.1503/cjs.008619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Lim KK, Matchar DB, Chong JL, Yeo W, Howe TS, Koh JSB. Pre-discharge prognostic factors of physical function among older adults with hip fracture surgery: a systematic review. Osteoporos Int 2019; 30:929-938. [PMID: 30643925 DOI: 10.1007/s00198-018-04831-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 12/21/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION To identify, organize, and assess the evidence level of pre-discharge prognostic factors of physical function beyond discharge after hip fracture surgery. METHODS We performed a systematic search of four databases (PubMed, Embase, CINAHL, PsycINFO) for longitudinal studies of prognostic factors of physical function at ≥ 1 month among older adults ≥ 50 years old with surgically treated hip fracture, complemented with hand-searching. Two reviewers independently screened papers for inclusion and assessed the quality of all the included papers using the Quality in Prognosis Studies (QUIPS) tool. We assigned the evidence level for each prognostic factor based on consistency in findings and study quality. RESULTS From 98 papers that met our inclusion criteria, we identified 107 pre-discharge prognostic factors and organized them into the following seven categories: demographic, physical, cognitive, psychosocial, socioeconomic, injury-related, and process of care. Potentially modifiable factors with strong or moderate evidence of an association included total length of stay, physical function at discharge, and grip strength. Factors with strong or moderate evidence of no association included gender, fracture type, and time to surgery. Factors with limited, conflicting, or inconclusive evidence included body-mass index, psychological resilience, depression, and anxiety. CONCLUSIONS Our findings highlight potentially modifiable prognostic factors that could be targeted and non-modifiable prognostic factors that could be used to identify patients who may benefit from more intensive intervention or to advise patients on their expectations on recovery. Examining the efficacies of existing interventions targeting these prognostic factors would inform future studies and whether any of such interventions could be incorporated into clinical practice.
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Affiliation(s)
- K K Lim
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Republic of Singapore.
| | - D B Matchar
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Republic of Singapore
- Department of Medicine (General Internal Medicine), Duke University Medical Center, Durham, NC, USA
| | - J L Chong
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Republic of Singapore
| | - W Yeo
- Orthopaedic Diagnostic Centre, Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Republic of Singapore
| | - T S Howe
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | - J S B Koh
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
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Mao C, Yuan JQ, Lv YB, Gao X, Yin ZX, Kraus VB, Luo JS, Chei CL, Matchar DB, Zeng Y, Shi XM. Associations between superoxide dismutase, malondialdehyde and all-cause mortality in older adults: a community-based cohort study. BMC Geriatr 2019; 19:104. [PMID: 30987591 PMCID: PMC6466801 DOI: 10.1186/s12877-019-1109-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/21/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Oxidative stress is an important theory of aging but population-based evidence has been lacking. This study aimed to evaluate the associations between biomarkers of oxidative stress, including plasma superoxide dismutase (SOD) activity and malondialdehyde (MDA), with all-cause mortality in older adults. METHODS This is a community-based cohort study of 2224 participants (women:1227, median age: 86 years). We included individuals aged 65 or above and with plasma SOD activity and/or MDA tests at baseline. We evaluated the hazard ratios (HRs) and 95% confidence intervals (CIs) by multivariable Cox models. RESULTS We documented 858 deaths during six years of follow-up. There was a significant interaction effect of sex with the association between SOD activity and mortality (P < 0.001). Compared with the lowest quintile, the risk of all-cause mortality was inversely associated with increasing quintiles of plasma SOD activity in women(P-trend< 0.001), with adjusted HRs for the second through fifth quintiles of 0.73 (95% CI 0.53-1.02), 0.52(95% CI 0.38-0.72), 0.53(95% CI 0.39-0.73), and 0.48(95% CI 0.35-0.66). There were no significant associations between SOD activity and mortality in men (P-trend = 0.64), and between MDA and mortality in all participants (P-trend = 0.79). CONCLUSIONS Increased activity of SOD was independently associated with lower all-cause mortality in older women but not in men. This epidemiological study lent support for the free radical/oxidative stress theory of aging.
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Affiliation(s)
- Chen Mao
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Jin-Qiu Yuan
- Scientific Research & International Exchange Department, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Yue-Bin Lv
- National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, #7 Panjiayuan Nanli, Chaoyang, Beijing, 100021, China
| | - Xiang Gao
- Nutritional Epidemiology Lab, Pennsylvania State University, Philadelphia, PA, USA
| | - Zhao-Xue Yin
- Nutritional Epidemiology Lab, Pennsylvania State University, Philadelphia, PA, USA
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute and Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jie-Si Luo
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Choy-Lye Chei
- Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - David Bruce Matchar
- Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
- Center for Study of Healthy Aging and Development Studies, Peking University, Beijing, China
| | - Yi Zeng
- Center for the study of Aging and Human Development and the Geriatric Division of School of Medicine, Duke University, Durham, North Carolina, USA
- Center for Study of Healthy Aging and Development Studies, Peking University, Beijing, China
| | - Xiao-Ming Shi
- National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, #7 Panjiayuan Nanli, Chaoyang, Beijing, 100021, China.
- Nutritional Epidemiology Lab, Pennsylvania State University, Philadelphia, PA, USA.
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Yeoh YS, Koh GCH, Tan CS, Tu TM, Singh R, Chang HM, De Silva DA, Ng YS, Ang YH, Yap P, Chew E, Merchant RA, Yeo TT, Chou N, Venketasubramanian N, Lee KE, Young SH, Hoenig H, Matchar DB, Luo N. Health-related quality of life loss associated with first-time stroke. PLoS One 2019; 14:e0211493. [PMID: 30689666 PMCID: PMC6349359 DOI: 10.1371/journal.pone.0211493] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/15/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES This study aimed to quantify health-related quality of life (HRQoL) loss associated with first episode of stroke by comparing patient-reported HRQoL before and after stroke onset. The impact of stroke in local population was also evaluated by comparing the pre- and post-stroke HRQoL with that of the general population. METHODS The HRQoL of stroke survivors was assessed with the EQ-5D-3L index score at recruitment, for recalled pre-stroke HRQoL, and at 3 and 12 month post-stroke. Change in HRQoL from pre-stroke to 3 and 12 month was self-reported by 285 and 238 patients, respectively. Mean EQ index score at each time point (baseline: 464 patients; 3 month post-stroke: 306 patients; 12 month post-stroke: 258 patients) was compared with published population norms for EQ-5D-3L. RESULTS There was a significant decrease in HRQoL at 3 (0.25) and 12 month (0.09) post-stroke when compared to the retrospectively recalled patients' mean pre-stroke HRQoL level (0.87). The reduction at 3 month was associated with the reduction in all EQ-5D-3L health dimensions; reductions remaining at 12 month were limited to dimensions of mobility, self-care, usual activities, and anxiety/depression. Stroke patients had a lower mean EQ index than the general population by 0.07 points pre-stroke (0.87 vs. 0.94), 0.33 points at 3 month (0.61 vs. 0.94) and 0.18 points at 12 month (0.76 vs. 0.94) post-stroke. CONCLUSIONS Stroke has a substantial impact on HRQoL in Singapore, especially in the first three months post-stroke. Compared to the general population, stroke survivors have lower HRQoL even before stroke onset. This pre-stroke deficit in HRQoL should be taken into account when quantifying health burden of stroke or setting goals for stroke rehabilitation.
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Affiliation(s)
- Yen Shing Yeoh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Rajinder Singh
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Hui Meng Chang
- Department of Neurology, Singapore General Hospital campus, National Neuroscience Institute, Singapore, Singapore
| | - Deidre A. De Silva
- Department of Neurology, Singapore General Hospital campus, National Neuroscience Institute, Singapore, Singapore
| | - Yee Sien Ng
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore, Singapore
| | - Yan Hoon Ang
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Philip Yap
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Effie Chew
- Department of Rehabilitation Medicine, National University Hospital, Singapore, Singapore
| | - Reshma A. Merchant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tseng Tsai Yeo
- Department of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Ning Chou
- Department of Neurosurgery, National University Hospital, Singapore, Singapore
| | | | - Kim En Lee
- Farrer Park Medical Centre, Farrer Park Hospital, Singapore, Singapore
| | - Sherry H. Young
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore, Singapore
| | - Helen Hoenig
- Physical Medicine & Rehabilitation Service, Durham Veterans Affairs Medical Center, Durham, North Carolina, United States of America
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - David Bruce Matchar
- Health Services & Systems Research Programme, Duke-NUS Medical School, Singapore, Singapore
- Center for Clinical Health Policy Research, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Nan Luo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Chong JL, Low LL, Chan DYL, Shen Y, Thin TN, Ong MEH, Matchar DB. Can we understand population healthcare needs using electronic medical records? Singapore Med J 2019; 60:446-453. [PMID: 30644525 DOI: 10.11622/smedj.2019012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Jia Loon Chong
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Lian Leng Low
- SingHealth Duke-NUS Family Medicine Academic Clinical Programme, Singapore.,Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
| | - Darren Yak Leong Chan
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
| | - Yuzeng Shen
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Thiri Naing Thin
- Health Services Research Unit, Singapore General Hospital, Singapore
| | - Marcus Eng Hock Ong
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - David Bruce Matchar
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Department of Medicine (General Internal Medicine), Duke University, Durham, NC, USA
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Yeoh YS, Koh GCH, Tan CS, Lee KE, Tu TM, Singh R, Chang HM, De Silva DA, Ng YS, Ang YH, Yap P, Chew E, Merchant RA, Yeo TT, Chou N, Venketasubramanian N, Young SH, Hoenig H, Matchar DB, Luo N. Can acute clinical outcomes predict health-related quality of life after stroke: a one-year prospective study of stroke survivors. Health Qual Life Outcomes 2018; 16:221. [PMID: 30463574 PMCID: PMC6249770 DOI: 10.1186/s12955-018-1043-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 11/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health-related quality of life (HRQoL) is a key metric to understand the impact of stroke from patients' perspective. Yet HRQoL is not readily measured in clinical practice. This study aims to investigate the extent to which clinical outcomes during admission predict HRQoL at 3 months and 1 year post-stroke. METHODS Stroke patients admitted to five tertiary hospitals in Singapore were assessed with Shah-modified Barthel Index (Shah-mBI), National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Mini-Mental State Examination (MMSE), and Frontal Assessment Battery (FAB) before discharge, and the EQ-5D questionnaire at 3 months and 12 months post-stroke. Association of clinical measures with the EQ index at both time points was examined using multiple linear regression models. Forward stepwise selection was applied and consistently significant clinical measures were analyzed for their association with individual dimensions of EQ-5D in multiple logistic regressions. RESULTS All five clinical measures at baseline were significant predictors of the EQ index at 3 months and 12 months, except that MMSE was not significantly associated with the EQ index at 12 months. NIHSS (3-month standardized β = - 0.111; 12-month standardized β = - 0.109) and mRS (3-month standardized β = - 0.122; 12-month standardized β = - 0.080) were shown to have a larger effect size than other measures. The contribution of NIHSS and mRS as significant predictors of HRQoL was mostly explained by their association with the mobility, self-care, and usual activities dimensions of EQ-5D. CONCLUSIONS HRQoL at 3 months and 12 months post-stroke can be predicted by clinical outcomes in the acute phase. NIHSS and mRS are better predictors than BI, MMSE, and FAB.
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Affiliation(s)
- Yen Shing Yeoh
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, Block MD1, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Gerald Choon-Huat Koh
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, Block MD1, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, Block MD1, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Kim En Lee
- Farrer Park Hospital, 1 Farrer Park Station Road, #10-08 Connexion, Singapore, Singapore
| | - Tian Ming Tu
- National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, Singapore
| | - Rajinder Singh
- National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, Singapore
| | - Hui Meng Chang
- National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, Singapore
| | - Deidre A De Silva
- Department of Neurology, Singapore General Hospital campus, National Neuroscience Institute, 20 College Road, Singapore, Singapore
| | - Yee Sien Ng
- Department of Rehabilitation Medicine, Singapore General Hospital, 20 College Road, Singapore, Singapore
| | - Yan Hoon Ang
- Geriatric Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, Singapore
| | - Philip Yap
- Geriatric Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, Singapore
| | - Effie Chew
- Department of Rehabilitation Medicine, National University Hospital, 5 Lower Kent Ridge Road, Singapore, Singapore
| | - Reshma Aziz Merchant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tseng Tsai Yeo
- Department of Neurosurgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, Singapore
| | - Ning Chou
- Department of Neurosurgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, Singapore
| | - N Venketasubramanian
- Raffles Neuroscience Centre, Raffles Hospital, 585 North Bridge Road, Singapore, Singapore
| | - Sherry H Young
- Department of Rehabilitation Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, Singapore
| | - Helen Hoenig
- Veterans Affairs Medical Center, 508 Fulton St, Durham, NC, USA.,Duke University Medical Center, Duke Box, Durham, NC, 3003, USA
| | - David Bruce Matchar
- Duke-NUS Medical School, 8 College Road, Singapore, Singapore.,Center for Clinical Health Policy Research, Duke University Medical Center, First Union Tower, 2200 W Main St, Suite, Durham, NC, 230, USA
| | - Nan Luo
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, Block MD1, 12 Science Drive 2, Singapore, 117549, Singapore.
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Affiliation(s)
- David Bruce Matchar
- Program in Health Services and Systems Research, Duke NUS Medical School, Singapore
| | - Josip Car
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gerald Choon Huat Koh
- Yong Loo Lin School of Medicine; Saw Swee Hock School of Public Health, NUS, Singapore
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Wong TH, Nadkarni NV, Nguyen HV, Lim GH, Matchar DB, Seow DCC, King NKK, Ong MEH. One-year and three-year mortality prediction in adult major blunt trauma survivors: a National Retrospective Cohort Analysis. Scand J Trauma Resusc Emerg Med 2018; 26:28. [PMID: 29669572 PMCID: PMC5907285 DOI: 10.1186/s13049-018-0497-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 04/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Survivors of trauma are at increased risk of dying after discharge. Studies have found that age, head injury, injury severity, falls and co-morbidities predict long-term mortality. The objective of our study was to build a nomogram predictor of 1-year and 3-year mortality for major blunt trauma adult survivors of the index hospitalization. Methods Using data from the Singapore National Trauma Registry, 2011–2013, we analyzed adults aged 18 and over, admitted after blunt injury, with an injury severity score (ISS) of 12 or more, who survived the index hospitalization, linked to death registry data. The study population was randomly divided 60/40 into separate construction and validation datasets, with the model built in the construction dataset, then tested in the validation dataset. Multivariable logistic regression was used to analyze 1-year and 3-year mortality. Results Of the 3414 blunt trauma survivors, 247 (7.2%) died within 1 year, and 551 (16.1%) died within 3 years of injury. Age (OR 1.06, 95% CI 1.05–1.07, p < 0.001), male gender (OR 1.53, 95% CI 1.12–2.10, p < 0.01), low fall from 0.5 m or less (OR 3.48, 95% CI 2.06–5.87, p < 0.001), Charlson comorbidity index of 2 or more (OR 2.26, 95% CI 1.38–3.70, p < 0.01), diabetes (OR 1.31, 95% CI 1.68–2.52, p = 0.04), cancer (OR 1.76, 95% CI 0.94–3.32, p = 0.08), head and neck AIS 3 or more (OR 1.79, 95% CI 1.13–2.84, p = 0.01), length of hospitalization of 30 days or more (OR 1.99, 95% CI 1.02–3.86, p = 0.04) were predictors of 1-year mortality. This model had a c-statistic of 0.85. Similar factors were found significant for the model predictor of 3-year mortality, which had a c-statistic of 0.83. Both models were validated on the second dataset, with an overall accuracy of 0.94 and 0.84 for 1-year and 3-year mortality respectively. Conclusions Adult survivors of major blunt trauma can be risk-stratified at discharge for long-term support.
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Affiliation(s)
- Ting Hway Wong
- Department of General Surgery, Singapore General Hospital / Duke-National University of Singapore Medical School, Outram Road, Singapore, 169608, Republic of Singapore.
| | | | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Canada
| | - Gek Hsiang Lim
- National Registry of Diseases Office, Health Promotion Board, Singapore, Singapore
| | | | - Dennis Chuen Chai Seow
- Department of Geriatric Medicine, Singapore General Hospital / Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Nicolas K K King
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital / Duke-National University of Singapore Medical School, Singapore, Singapore
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Malhotra R, Chei CL, Menon EB, Chow WL, Quah S, Chan A, Ajay S, Matchar DB. Trajectories of positive aspects of caregiving among family caregivers of stroke-survivors: the differential impact of stroke-survivor disability. Top Stroke Rehabil 2018; 25:261-268. [DOI: 10.1080/10749357.2018.1455369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Rahul Malhotra
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore, Singapore
| | - Choy-Lye Chei
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore, Singapore
| | | | - Wai-Leng Chow
- Health Services Research, Eastern Health Alliance, Singapore, Singapore
| | - Stella Quah
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Angelique Chan
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore, Singapore
| | - Shweta Ajay
- Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore, Singapore
| | - David Bruce Matchar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
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Wong AKS, Ong SF, Matchar DB, Lie D, Ng R, Yoon KE, Wong CH. Complexities and Challenges of Singapore Nurses Providing Postacute Home Care in Multicultural Communities: A Grounded Theory Study. J Transcult Nurs 2018; 29:402-409. [PMID: 29308714 DOI: 10.1177/1043659617736884] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Studies are needed to inform the preparation of community nurses to address patient behavioral and social factors contributing to unnecessary readmissions to hospital. This study uses nurses' input to understand challenges faced during home care, to derive a framework to address the challenges. METHODS Semistructured interviews were conducted to saturation with 16 community nurses in Singapore. Interviews were transcribed verbatim and transcripts independently coded for emergent themes. Themes were interpreted using grounded theory. RESULTS Seven major themes emerged from 16 interviews: Strained social relationships, complex care decision-making processes within families, communication barriers, patient's or caregiver neglect of health issues, building and maintaining trust, trial-and-error nature of work, and dealing with uncertainty. DISCUSSION Community nurses identified uncertainty arising from complexities in social-relational, personal, and organizational factors as a central challenge. Nursing education should focus on navigating and managing uncertainty at the personal, patient, and family levels.
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Affiliation(s)
| | - Shu Fen Ong
- 2 Khoo Teck Puat Hospital, Alexandra Health System, Singapore, Singapore
| | | | - Desiree Lie
- 3 Duke-NUS Medical School, Singapore, Singapore
| | - Reuben Ng
- 5 Lee Kuan Yew School of Public Policy, National University of Singapore
| | | | - Chek Hooi Wong
- 2 Khoo Teck Puat Hospital, Alexandra Health System, Singapore, Singapore.,3 Duke-NUS Medical School, Singapore, Singapore.,6 Geriatric Education and Research Institute, Singapore
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Lv YB, Zhu PF, Yin ZX, Kraus VB, Threapleton D, Chei CL, Brasher MS, Zhang J, Qian HZ, Mao C, Matchar DB, Luo JS, Zeng Y, Shi XM. A U-shaped Association Between Blood Pressure and Cognitive Impairment in Chinese Elderly. J Am Med Dir Assoc 2017; 18:193.e7-193.e13. [PMID: 28126139 PMCID: PMC5294228 DOI: 10.1016/j.jamda.2016.11.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/10/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Higher or lower blood pressure may relate to cognitive impairment, whereas the relationship between blood pressure and cognitive impairment among the elderly is not well-studied. The study objective was to determine whether blood pressure is associated with cognitive impairment in the elderly, and, if so, to accurately describe the association. DESIGN Cross-sectional data from the sixth wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) conducted in 2011. SETTING Community-based setting in longevity areas in China. PARTICIPANTS A total of 7144 Chinese elderly aged 65 years and older were included in the sample. MEASURES Systolic blood pressures (SBP) and diastolic blood pressures (DBP) were measured, pulse pressure (PP) was calculated as (SBP) - (DBP) and mean arterial pressures (MAP) was calculated as 1/3(SBP) + 2/3(DBP). Cognitive function was assessed via a validated Mini-Mental State Examination (MMSE). RESULTS Based on the results of generalized additive models (GAMs), U-shaped associations were identified between cognitive impairment and SBP, DBP, PP, and MAP. The cutpoints at which risk for cognitive impairment (MMSE <24) was minimized were determined by quadratic models as 141 mm Hg, 85 mm Hg, 62 mm Hg, and 103 mm Hg, respectively. In the logistic models, U-shaped associations remained for SBP, DBP, and MAP but not PP. Below the identified cutpoints, each 1-mm Hg decrease in blood pressure corresponded to 0.7%, 1.1%, and 1.1% greater risk in the risk of cognitive impairment, respectively. Above the cutpoints, each 1-mm Hg increase in blood pressure corresponded to 1.2%, 1.8%, and 2.1% greater risk of cognitive impairment for SBP, DBP, and MAP, respectively. CONCLUSION A U-shaped association between blood pressure and cognitive function in an elderly Chinese population was found. Recognition of these instances is important in identifying the high-risk population for cognitive impairment and to individualize blood pressure management for cognitive impairment prevention.
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Affiliation(s)
- Yue-Bin Lv
- Institute of Environmental Health and Related Products Safety, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Peng-Fei Zhu
- Institute of Environmental Health and Related Products Safety, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhao-Xue Yin
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute and Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Diane Threapleton
- Division of Epidemiology, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Choy-Lye Chei
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Melanie Sereny Brasher
- Department of Sociology and Anthropology, Department of Human Development and Family Studies, University of Rhode Island, Kingston, RI
| | - Juan Zhang
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Han-Zhu Qian
- Vanderbilt Institute for Global Health, Division of Epidemiology, Department of Medicine, Vanderbilt University, Nashville, TN
| | - Chen Mao
- Division of Epidemiology, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - David Bruce Matchar
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jie-Si Luo
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yi Zeng
- Center for the Study of Aging and Human Development and the Geriatric Division of School of Medicine, Duke University, Durham, NC; Center for Study of Healthy Aging and Development Studies, Peking University, Beijing, China
| | - Xiao-Ming Shi
- Institute of Environmental Health and Related Products Safety, Chinese Center for Disease Control and Prevention, Beijing, China.
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Lv YB, Yin ZX, Chei CL, Brasher MS, Zhang J, Kraus VB, Qian F, Shi XM, Matchar DB, Zeng Y. Serum Cholesterol Levels within the High Normal Range Are Associated with Better Cognitive Performance among Chinese Elderly. J Nutr Health Aging 2017. [PMID: 26892577 DOI: 10.1007/s12603-016-0701-6.] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The association between cognitive function and cholesterol levels is poorly understood and inconsistent results exist among the elderly. The purpose of this study is to investigate the association of cholesterol level with cognitive performance among Chinese elderly. DESIGN A cross-sectional study was implemented in 2012 and data were analyzed using generalized additive models, linear regression models and logistic regression models. SETTING Community-based setting in eight longevity areas in China. SUBJECTS A total of 2000 elderly aged 65 years and over (mean 85.8±12.0 years) participated in this study. MEASUREMENTS Total cholesterol (TC), triglycerides (TG), low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) concentration were determined and cognitive impairment was defined as Mini-Mental State Examination (MMSE) score ≤23. RESULTS There was a significant positive linear association between TC, TG, LDL-C, HDL-C and MMSE score in linear regression models. Each 1 mmol/L increase in TC, TG, LDL-C and HDL-C corresponded to a decreased risk of cognitive impairment in logistic regression models. Compared with the lowest tertile, the highest tertile of TC, LDL-C and HDL-C had a lower risk of cognitive impairment. The adjusted odds ratios and 95% CI were 0.73(0.62-0.84) for TC, 0.81(0.70-0.94) for LDL-C and 0.81(0.70-0.94) for HDL-C. There was no gender difference in the protective effects of high TC and LDL-C levels on cognitive impairment. However, for high HDL-C levels the effect was only observed in women. High TC, LDL-C and HDL-C levels were associated with lower risk of cognitive impairment in the oldest old (aged 80 and older), but not in the younger elderly (aged 65 to 79 years). CONCLUSIONS These findings suggest that cholesterol levels within the high normal range are associated with better cognitive performance in Chinese elderly, specifically in the oldest old. With further validation, low cholesterol may serve a clinical indicator of risk for cognitive impairment in the elderly.
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Affiliation(s)
- Y-B Lv
- Dr. Xiaoming Shi, No. 7 Pan Jia Yuan Nan Li, Chaoyang District, Beijing 100021, China. Telephone: (+86) 1050930101, Fax:(+86)1050930115, E-mail:
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Abstract
We performed a review of the economic literature to identify what is known about the relationship between Expanded Disability Status Scale (EDSS) categories and cost of multiple sclerosis (MS). We sought cohort studies of patients with multiple sclerosis that described the costs attributed to each EDSS score and utilized specific inclusion criteria for the selection of 10 studies. We found that both direct and indirect costs rise continuously with increasing EDSS category, and this rise is qualitatively exponential. The rise in indirect costs appears at lower EDSS scores. The cost of a relapse occurring in any given EDSS category exceeds that associated with that particular EDSS category. Few studies comprehensively assessed the entire spectrum of the costs, and much of the literature is based on EDSS categories in coarse groupings. In spite of several variations between studies, one important conclusion that we can draw is that rise in cost is positively correlated to scores on the EDSS categories, and therefore agents with a capacity to prevent or arrest the rate of MS progression may affect the overall cost of MS.
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Affiliation(s)
- M B Patwardhan
- Duke Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC 27705, USA.
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Lv YB, Yin ZX, Chei CL, Brasher MS, Zhang J, Kraus VB, Qian F, Shi XM, Matchar DB, Zeng Y. Serum cholesterol levels within the high normal range are associated with better cognitive performance among Chinese elderly. J Nutr Health Aging 2016; 20:280-7. [PMID: 26892577 DOI: 10.1007/s12603-016-0701-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Y-B Lv
- Dr. Xiaoming Shi, No. 7 Pan Jia Yuan Nan Li, Chaoyang District, Beijing 100021, China. Telephone: (+86) 1050930101, Fax:(+86)1050930115, E-mail:
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Affiliation(s)
- David Bruce Matchar
- From the Department of Medicine, Duke University Medical Center, Durham, NC (D.B.M.); and Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (D.B.M., H.V.N., Y.T.)
| | - Hai V. Nguyen
- From the Department of Medicine, Duke University Medical Center, Durham, NC (D.B.M.); and Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (D.B.M., H.V.N., Y.T.)
| | - Yuan Tian
- From the Department of Medicine, Duke University Medical Center, Durham, NC (D.B.M.); and Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (D.B.M., H.V.N., Y.T.)
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Lv YB, Yin ZX, Chei CL, Qian HZ, Kraus VB, Zhang J, Brasher MS, Shi XM, Matchar DB, Zeng Y. Low-density lipoprotein cholesterol was inversely associated with 3-year all-cause mortality among Chinese oldest old: data from the Chinese Longitudinal Healthy Longevity Survey. Atherosclerosis 2015; 239:137-42. [PMID: 25602855 DOI: 10.1016/j.atherosclerosis.2015.01.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 12/25/2014] [Accepted: 01/05/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Low-density lipoprotein cholesterol (LDL-C) is a risk factor for survival in middle-aged individuals, but conflicting evidence exists on the relationship between LDL-C and all-cause mortality among the elderly. The goal of this study was to assess the relationship between LDL-C and all-cause mortality among Chinese oldest old (aged 80 and older) in a prospective cohort study. METHODS LDL-C concentration was measured at baseline and all-cause mortality was calculated over a 3-year period. Multiple statistical models were used to adjust for demographic and biological covariates. RESULTS During three years of follow-up, 447 of 935 participants died, and the overall all-cause mortality was 49.8%. Each 1 mmol/L increase of LDL-C concentration corresponded to a 19% decrease in 3-year all-cause mortality (hazard ratio [HR] 0.81, 95% confidence interval [CI] 0.71-0.92). The crude HR for abnormally higher LDL-C concentration (≥3.37 mmol/L) was 0.65 (0.41-1.03); and the adjusted HR was statistically significant around 0.60 (0.37-0.95) when adjusted for different sets of confounding factors. Results of sensitivity analysis also showed a significant association between higher LDL-C and lower mortality risk. CONCLUSIONS Among the Chinese oldest old, higher LDL-C level was associated with lower risk of all-cause mortality. Our findings suggested the necessity of re-evaluating the optimal level of LDL-C among the oldest old.
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Affiliation(s)
- Yue-Bin Lv
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhao-Xue Yin
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Choy-Lye Chei
- Health Services and Systems Research, Duke-NUS Graduate Medical School Singapore, Singapore
| | - Han-Zhu Qian
- Vanderbilt Institute for Global Health, Division of Epidemiology, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Juan Zhang
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Melanie Sereny Brasher
- Department of Sociology and Anthropology, Department of Human Development and Family Studies, University of Rhode Island, Kingston, RI, USA
| | - Xiao-Ming Shi
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China.
| | - David Bruce Matchar
- Health Services and Systems Research, Duke-NUS Graduate Medical School Singapore, Singapore; Center for Clinical Health Policy Research and Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Yi Zeng
- Center for the Study of Aging and Human Development and the Geriatric Division of School of Medicine, Duke University, Durham, NC, USA; Center for Study of Healthy Aging and Development Studies, Peking University, Beijing, China.
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Chin CT, Mellstrom C, Chua TSJ, Matchar DB. Lifetime cost-effectiveness analysis of ticagrelor in patients with acute coronary syndromes based on the PLATO trial: a Singapore healthcare perspective. Singapore Med J 2013; 54:169-75. [PMID: 23546032 DOI: 10.11622/smedj.2013045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Ticagrelor 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. METHODS This 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. RESULTS Ticagrelor 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. CONCLUSION Based 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.
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Affiliation(s)
- Chee Tang Chin
- Department of Cardiology, National Heart Centre Singapore, Mistri Wing, 17 Third Hospital Avenue, Singapore.
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