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Lower extremity muscle strength, and functional limitations are important modifiable predictors of falls, but are often examined using performance based measures. We examined the association between self-reported physical function limitations, determined using Late-Life Function and Disability Instrument(LLFDI) and incident falls in community-dwelling elderly individuals. 283 older adults participants were included in this analysis. Physical function limitations were defined as a person’s difficulty in completing items of the lower extremity function domain and composite scores of the LLFDI. Information on falls was obtained through a standardised questionnaire. At one-year follow-up, 15.2% (43) of the participants experienced their first fall. In the multivariable analysis, individuals who reported difficulties in items of lower extremity function domain were more likely to experience a fall (incidence rate ratio[IRR]: ranging between 2.43 and 7.01; all P ≤ 0.046). In addition, decreasing advanced lower extremity function scores (IRR: 1.70, 95% confidence interval[CI]): 1.04, 2.78) and overall function component score (IRR: 2.05, 95% CI: 1.22, 3.44) were associated with higher risk of incident falls. Physical function limitations, determined using LLFDI, were associated with incident falls. Our findings provide further evidence that the LLFDI function component has the potential to be used as a self-assessment tool for fall risk.

We estimated the generation interval distribution for coronavirus disease on the basis of serial intervals of observed infector-infectee pairs from established clusters in Singapore. The short mean generation interval and consequent high prevalence of presymptomatic transmission requires public health control measures to be responsive to these characteristics of the epidemic.

ObjectivesAsia's first national advance care planning (ACP) program was established in Singapore in 2011 to enhance patient autonomy and self-determination in end-of-life (EoL) care decision-making. However, no known study has examined the extent to which ACP in Singapore successfully met its aims. The purpose of the current study was to examine the attitudes of local healthcare professionals on patients’ autonomy in decision-making at the EoL since they strongly influence the extent to which patient and family wishes are fulfilled.MethodsGuided by the Interpretive-Systemic Framework and Proctor's conceptual taxonomy of implementation research outcomes, an interview guide was developed. Inquiries focused on healthcare professionals’ attitudes towards ACP, their clinical experiences working with patients and families, and their views on program effectiveness. Sixty-three physicians, nurses, medical social workers, and designated ACP coordinators who were actively engaged in ACP facilitation were recruited from seven major hospitals and specialist centers in Singapore through purposive sampling. Twelve interpretive-systemic focus groups were conducted, recorded, transcribed, and analyzed using a thematic analysis.ResultsThe extent to which patients in Singapore can exert autonomy in EoL care decision-making is influenced by five themes: (i) collusion over truth-telling to patient, (ii) deferment of autonomy by patients, (iii) negotiating patient self-determination, (iv) relational autonomy as the gold standard and (v) barriers to realization of patient choices.Significance of resultsHealthcare practitioners in Asian communities must align themselves with the values and needs of patients and their family and jointly make decisions that are consistent and congruent with the values of patients and their families. Sensitivity towards such cross-cultural practices is key to enhancing ACP awareness, discourse, and acceptability in Asian communities.

Background Despite being simply defined as a process to further one's understanding about future medical care, the process of implementing advance care planning (ACP) within acute hospital settings can be complex. Aim We describe different ACP service models adopted in Singapore, and the facilitators for, and barriers to, its effective implementation. Design Qualitative focus group study with thematic analysis. Settings/participants We purposefully sampled four stakeholder groups involved in the implementation of ACP. Our sample included 63 participants, 12 physicians, 15 nurses, 24 medical social workers, and 12 ACP coordinators from seven public hospitals and one specialist center. Results We describe three different acute-care models adopted in Singapore, differentiated by leadership approach, target population, delivery process, and job roles. Our results revealed nine themes, organized into four categories, including: (1) hospital culture (curative norms, absence of preference-supportive culture), (2) organizational priority and leadership (low priority on hospital agenda, inappropriate leadership), (3) goals and distinction (lack of shared purpose and goals, no clear differentiation from existing practices), and (4) work practices (pigeonholing of ACP practice, inappropriate resourcing, accountability and feedback). Conclusion We learned that to implement ACP effectively in an acute-care setting, there needs to be a cultural and behavioral transformation, led by committed and empowered leaders. Organizations that can create a shared purpose built on an ethos of honoring patients' preferences, and support this with systematic processes and adequate resourcing, will be more equipped to implement ACP effectively.

ObjectiveThis study aims to quantify medical care utilisation, and to describe the cost trajectories of individuals with advanced illnesses in the last-year of life, differentiated by advanced cancer, end-stage organ failure and progressive neurological disorders.MethodsThis retrospective database study included decedents who had previous inpatient or outpatient encounters at a public hospital in Singapore. Patients with advanced diseases were identified based on diagnostic codes and clinical criteria. Using a look-back approach, the amount of healthcare services utilised and the corresponding mean monthly and annual costs to the healthcare system in the last 12-months of life were quantified.ResultsThe last 12-months of life among 6,598 decedents was associated with £20,524 (95% confidence interval: £20,013–£21,036) in medical costs, of which 80% was accounted for by inpatient admissions. Costs increased sharply in the last 2-months of life, with a large proportion of monthly costs accounted for by inpatient admissions which rose rapidly from 61% at 12-months prior to death to 94% in the last-month of life. Compared to patients with cancer, individuals diagnosed with non-cancer advanced illnesses accumulated 1.6 times more healthcare costs in the last-year of life with significant differences across patients with end-stage organ failure and progressive neurological disorders.ConclusionHealthcare costs varied across disease conditions at the end-of-life. With advance care planning and close collaboration between the inpatient clinical team and the community providers, it may be possible to re-direct some of the hospitalisation costs to community-based palliative care services.

Objective To develop a risk score for the real-time prediction of readmissions for patients using patient specific information captured in electronic medical records (EMR) in Singapore to enable the prospective identification of high-risk patients for enrolment in timely interventions. Methods Machine-learning models were built to estimate the probability of a patient being readmitted within 30 days of discharge. EMR of 25,472 patients discharged from the medicine department at Ng Teng Fong General Hospital between January 2016 and December 2016 were extracted retrospectively for training and internal validation of the models. We developed and implemented a real-time 30-day readmission risk score generation in the EMR system, which enabled the flagging of high-risk patients to care providers in the hospital. Based on the daily high-risk patient list, the various interfaces and flow sheets in the EMR were configured according to the information needs of the various stakeholders such as the inpatient medical, nursing, case management, emergency department, and postdischarge care teams. Results Overall, the machine-learning models achieved good performance with area under the receiver operating characteristic ranging from 0.77 to 0.81. The models were used to proactively identify and attend to patients who are at risk of readmission before an actual readmission occurs. This approach successfully reduced the 30-day readmission rate for patients admitted to the medicine department from 11.7% in 2017 to 10.1% in 2019 (p Conclusion Machine-learning models can be deployed in the EMR system to provide real-time forecasts for a more comprehensive outlook in the aspects of decision-making and care provision.

Background: Smartphone apps could support patients and caregivers in disease self-management. However, as patients’ experiences and needs might not always align with clinical judgments, the eliciting and engaging of perspectives of all stakeholders in the smartphone app design process is of paramount importance. Objective: The aims of this study are to better understand the needs of and challenges facing caregivers and health care professionals (HCPs) who care for children with atopic dermatitis (AD) and to explore the desirable features and content of a smartphone app that would support AD self-management. Methods: This study adopted a qualitative participatory co-design methodology involving 3 focus group discussions: workshop one focused on caregivers; workshop two engaged with HCPs; and in the last workshop, caregivers and digital health experts were asked to design the wireframe prototype. The participants completed a sociodemographic questionnaire, a technology acceptance questionnaire, and a workshop evaluation form. Results: Twelve caregivers participated in the first workshop, and 10 HCPs participated in the second workshop. Eight caregivers and 4 digital health experts attended the third workshop. Three superordinate themes that reflected caregivers’ and HCPs’ challenges and needs were identified: empowerment by education, confusion over treatment, and emotional impact. Workshop participants also raised a series of suggestions on the features and contents of the AD self-management app, which informed the last co-design workshop, and described their needs and challenges. In the last workshop, the participants developed a wireframe prototype of the app following the identified requirements and recommendations. Conclusions: The co-design approach was found to be a successful way of engaging with the participants, as it allowed them to express their creativity and helped us to articulate the root of the clinical problems. The co-design workshop was successful in creating and generating new ideas and solutions for smartphone app development. Nanyang Technological University Published version This research was funded by a principal investigator start-up grant (Lee Kong Chian School of Medicine, Nanyang Technological University). JC’s post at Imperial College London is supported by the National Institute for Health Research NW London Applied Research Collaboration.

Background Frailty is frequently found to be associated with increased healthcare utilisation in western countries, but little is known in Asian population. This study was conducted to investigate the association between frailty and healthcare utilisation by care setting among community-dwelling older adults in Singapore.Methods We conducted a six-month look-back and six-month post-baseline analysis of healthcare utilisation. Data from a longitudinal population-based survey were linked with healthcare utilisation data obtained from an administrative database. Baseline frailty status was measured using the five-item FRAIL scale, which is categorised into three groups: robust (0), pre-frail (1–2), and frail (3–5). Healthcare utilisation included government primary care clinic visits, specialised outpatient clinic visits, emergency department visits, day surgery and hospitalisations. Multivariable logistic and negative binomial regression were applied to examine the associations between frailty with healthcare utilisation, controlling for other confounding variables. Results In our sample of 701 older adults, 64.8% were of robust health, 27.7% belonged to the pre-frail category, and 7.6% were frail. Compared to the non-frail group, frail individuals had a higher rate of specialised outpatient clinic visits (incidence rate ratio (IRR): 2.8, 95% confidence interval (CI): 1.2-6.5), emergency department visits (IRR: 3.1, 95%CI: 1.1-8.1), day surgeries done (IRR: 6.4, 95%CI: 1.3-30.9), and hospitalisations (IRR: 6.7, 95%CI: 2.1-21.1) in the six-months before the baseline and in subsequent six months (IRR: 3.3, 95%CI: 1.6-7.1; 6.4, 2.4-17.2; 5.8, 1.3-25.8; 13.1, 4.9-35.0; respectively). Frailty was also significantly associated with an increased in the number of specialised outpatient clinic visits, emergency department visits and hospitalisations in 6 months before and after baseline, with controlling for covariates. Conclusions Among community-dwelling adults, frailty was positively associated with the likelihood and the number of specialised outpatient clinic visits, emergency department visits, day surgeries and hospitalisations but no significant associations were observed with primary care utilization. The positive association was significant at 6-month before and after the baseline. As frailty is a potentially reversible health state with early screening and intervention, providing preventive activities that delay the onset or progression of frailty should have the potential effect on delaying secondary and tertiary care needs.

Background Around the world, different models of paediatric palliative care have responded to the unique needs of children with life shortening conditions. However, research confirming their utility and impact is still lacking. This study compared patient-related outcomes and healthcare expenditures between those who received home-based paediatric palliative care and standard care. The quality of life and caregiver burden for patients receiving home-based paediatric palliative care were also tracked over the first year of enrolment to evaluate the service’s longitudinal impact. Method A structured impact and cost evaluation of Singapore-based HCA Hospice Care’s Star PALS (Paediatric Advance Life Support) programme was conducted over a three-year period, employing both retrospective and prospective designs with two patient groups. Results Compared to the control group (n = 67), patients receiving home-based paediatric palliative care (n = 71) spent more time at home than in hospital in the last year of life by 52 days (OR = 52.30, 95% CI: 25.44–79.17) with at least two fewer hospital admissions (OR = 2.46, 95% CI: 0.43–4.48); and were five times more likely to have an advance care plan formulated (OR = 5.51, 95% CI: 1.55–19.67). Medical costs incurred by this group were also considerably lower (by up to 87%). Moreover, both patients’ quality of life (in terms of pain and emotion), and caregiver burden showed improvement within the first year of enrolment into the programme. Discussion Our findings suggest that home-based paediatric palliative care brings improved resource utilization and cost-savings for both patients and healthcare providers. More importantly, the lives of patients and their caregivers have improved, with terminally ill children and their caregivers being able to spend more quality time at home at the final stretch of the disease. Conclusions The benefits of a community paediatric palliative care programme have been validated. Study findings can become key drivers when engaging service commissioners or even policy makers in appropriate settings.

Aim With an aging Singapore population, there is an increasing demand for dementia care. The present study aimed to evaluate the effectiveness and cost-effectiveness of the Primary Care Dementia Clinic (PCDC) in comparison with the Memory Clinic (MC; hospital-based) and other polyclinics. Methods A quasi-experimental design was implemented. Effectiveness of PCDC was assessed through caregiver satisfaction, quality of life (caregiver-rated) and adverse events rates. Quality-of-Life measures using the EuroQol 5 Dimension Questionnaire (EQ-5D) at baseline, 6 months and 12 months was assessed. Costs were calculated from a societal perspective. The incremental cost-effectiveness of the PCDC was compared with MC and other polyclinics. Results The present study showed that quality of life and the rate of adverse events at 12 months were similar between the three groups. Caregiver satisfaction at 12 months was higher in the PCDC group when compared with other polyclinics. There were no observed differences in societal cost between the three groups. At 6-month follow up, direct medical costs for PCDC were significantly lower that of other polyclinics. At 12-month follow up, PCDC patients had higher Quality Adjusted Life Years (QALYs) compared with the MC group. Conclusion PCDC provided effective care, similar to care at MC and better than care at other polyclinics. Caregiver satisfaction was higher for the PCDC group, and PCDC patients had lower direct medical costs at 6-month follow up. Given these findings, adopting a PCDC model in other polyclinics in Singapore can be beneficial for optimal right siting of patients. Geriatr Gerontol Int 2018; 18: 479-486.

ObjectivesTo determine the economic benefit of an integrated home-based palliative care programme for advanced dementia (Programme Dignity), evaluation is required. This study aimed to estimate Programme Dignity’s average monthly cost from a provider’s perspective; and compare healthcare utilisation and costs of programme patients with controls, accounting for enrolment duration.MethodsThis was a retrospective cohort study. Home-dwelling patients with advanced dementia (stage 7 on the functional assessment staging in Alzheimer’s disease) with a history of pneumonia, albumin ResultsThe average monthly programme cost was SGD$1311 (SGD-Pounds exchange rate: 0.481) per patient. Fully enrolled programme patients were less likely to visit the emergency department (incidence rate ratios (IRRs): 1 month=0.56; 3 months=0.19; 6 months=0.10; all pConclusionProgramme Dignity for advanced dementia reduces healthcare utilisation and costs. If scalable, it may benefit more patients wishing to remain at home at the end-of-life, allowing for a potentially sustainable care model to cope with rapid population ageing. It contributes to the evidence base of advanced dementia palliative care and informs healthcare policy making. Future studies should estimate informal caregiving costs for comprehensive economic evaluation.

Background To examine the underpinnings of Asia’s first national Advance Care Planning (ACP) programme, and to identify the dynamics, mechanisms and systemic factors that influence the implementation of ACP in Singapore. Methods A qualitative interpretive-systemic focus group study with 4 professional stakeholder groups who played critical roles in the ACP programme. Study included 63 physicians, nurses, medical social worker and allied health workers from 7 public hospitals and specialist center that incorporated ACP into clinical practice. Results Framework analysis revealed 19 themes, organized into 5 categories including: (1) Life and Death Culture (social perception of death, biomedical model, health system hierarchy, health seeking behaviors), (2) ACP Coordination (institutional leadership, programme receptiveness, interdisciplinary trust, preparatory training), (3) ACP Administration (practice diversity, work flow, operation clarity), (4) ACP Outcomes (care preferences, medical-social dissonance, performance measures, intrinsic values), and (5) Sustainability Shift (public life and death education, holistic end-of-life care training, governance and service alignment, empowered citizenry). These further formed an interpretive-systemic framework of sustainable ACP, reflecting the social, cultural, political, operational and spiritual contexts that support national ACP development. Conclusion This research provides insights on developmental and implementation challenges of Asia’s first national ACP programme. ACP should be supported by public health strategy for enhancing individual, professional, and institutional readiness for end-of-life conversation before programme commencement. It emphasizes the importance of health policy, organizational structure, social discourse, and shared meaning in planning and delivery of ACP to aid care decision making among Asian patients and their families facing terminal illness and mortality.

Background: Terminally ill patients at the end-of-life do transit between care settings due to their complex care needs. Problems of care fragmentation could result in poor quality of care. Aim: We aimed to evaluate the impact of an integrated hospice home care programme on acute care service usage and on the share of home deaths. Settings/participants: The retrospective study cohort comprised patients who were diagnosed with cancer, had an expected prognosis of 1 year or less, and were referred to a home hospice. The intervention group comprised deceased patients enrolled in the integrated hospice home care programme between September 2012 and June 2014. The historical comparison group comprised deceased patients who were referred to other home hospices between January 2007 and January 2011. Results: There were 321 cases and 593 comparator subjects. Relative to the comparator group, the share of hospital deaths was significantly lower for programme participants (12.1% versus 42.7%). After adjusting for differences at baseline, the intervention group had statistically significantly lower emergency department visits at 30 days (incidence rate ratio: 0.38; 95% confidence interval: 0.31–0.47), 60 days (incidence rate ratio: 0.61; 95% confidence interval: 0.54–0.69) and 90 days (incidence rate ratio: 0.69; 95% confidence interval: 0.62–0.77) prior to death. Similar results held for the number of hospitalisations at 30 days (incidence rate ratio: 0.48; 95% confidence interval: 0.40–0.58), 60 days (incidence rate ratio: 0.71; 95% confidence interval: 0.62–0.82) and 90 days (incidence rate ratio: 0.77; 95% confidence interval: 0.68–0.88) prior to death. Conclusion: Our results demonstrated that by integrating services between acute care and home hospice care, a reduction in acute care service usage could occur.

Background : Many middle- and high-income countries face the challenge of meeting preferences for home deaths. A better understanding of associated factors could support the design and implementation of policies and practices to enable dying at home. This study aims to identify factors associated with the place of death in Singapore, a country with a strong sense of filial piety. Settings/participants : A retrospective cohort of 62,951 individuals (≥21 years old) who had died from chronic diseases in Singapore between 2012–2015 was obtained. Home death was defined as a death that occurred in a private residence whereas non-home deaths occurred in hospitals, nursing homes, hospices and other locations. Data were obtained by extracting and linking data from five different databases. Hierarchical multivariable logistic regression models were used to examine the effects of individual, clinical and system factors sequentially. Results : Twenty-eight percent of deaths occurred at home. Factors associated with home death included being 85 years old or older (OR 4.45, 95% CI 3.55–5.59), being female (OR 1.21, 95% CI 1.16–1.25), and belonging to Malay ethnicity (OR 1.91, 95% CI 1.82–2.01). Compared to malignant neoplasm, deaths as a result of diabetes mellitus (OR 1.93, 95% CI 1.69–2.20), and cerebrovascular diseases (OR 1.28, 95% CI 1.19–1.36) were also associated with a higher likelihood of home death. Independently, receiving home palliative care (OR 3.45, 95% CI 3.26–3.66) and having a documented home death preference (OR 5.08, 95% CI 3.96–6.51) raised the odds of home deaths but being admitted to acute hospitals near the end-of-life was associated with lower odds (OR 0.92, 95% CI 0.90–0.94). Conclusion : Aside from cultural and clinical factors, system-based factors including access to home palliative care and discussion and documentation of preferences were found to influence the likelihood of home deaths. Increasing home palliative care capacity and promoting advance care planning could facilitate home deaths if this is the desired option of patients. NMRC (Natl Medical Research Council, S’pore) MOH (Min. of Health, S’pore) Published version

Background. Advance care planning (ACP) involves important decision making about future medical needs. The high-volume and disparate nature of ACP research makes it difficult to grasp the evidence and derive clear policy lessons for policymakers and clinicians.Aim. The aim of this study was to synthesize ACP research evidence and identify relevant contextual elements, program features, implementation principles, and impacted outcomes to inform policy and practice.Design. An overview of systematic reviews using the Cochrane Handbook of Systematic Reviews of Interventions was performed. Study quality was assessed using a modified version of the AMSTAR (A MeaSurement Tool to Assess Reviews) tool.Data Sources. MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE were searched for ACP-related research from inception of each database to April 2017. Searches were supplemented with gray literature and manual searches. Eighty systematic reviews, covering over 1660 original articles, were included in the analysis.Results. Legislations, institutional policies, and cultural factors influence ACP development. Positive perceptions toward ACP do not necessarily translate into more end-of-life conversations. Many factors related to patients' and providers' attitudes, and perceptions toward life and mortality influence ACP implementation, decision making, and completion. Limited, low-quality evidence points to several ACP benefits, such as improved end-of-life communication, documentation of care preferences, dying in preferred place, and health care savings. Recurring features that make ACP programs effective include repeated and interactive discussion sessions, decision aids, and interventions targeting multiple stakeholders.Conclusions. Preliminary evidence highlights several elements that influence the ACP process and provides a variety of features that could support successful, effective, and sustainable ACP implementation. However, this evidence is compartmentalized and limited. Further studies evaluating ACP as a unified program and assessing the impact of ACP for different populations, settings, and contexts are needed to develop programs that are able to unleash ACP's full potential. (C) 2018 The Authors. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).

Context One of the key outcomes of advance care planning is whether patients had received care that was consistent with their expressed goals and preferences. Objectives The aims of this study were to illustrate the feasibility of using routinely collected health care data that include hospital procedural codes, diagnosis-related codes, health services utilization, and death registry data and to ascertain the level of concordance between care received and the stated goals. Methods In this retrospective cohort study, medical treatments were ascertained using a combination of hospital procedural codes and diagnosis-related codes. Places of care were obtained by reviewing the sequence of health services used, and the place of death was obtained from the national death registry. To ascertain concordance, medical treatment, places of care, and place of death were compared against the individual's preferences. Results The sample includes 1731 decedents (aged 21 years and above) who completed their advance care planning documentation as part of a national program. Ninety-eight percent who wished for comfort measures met their preferences. Sixty-five percent of individuals who wished to be cared for at home received care at home. Nearly 40% of all individuals who opted to die at home achieved their wishes, whereas 76% of those who opted for home or hospital and home or hospice had their preferences fulfilled. Conclusion Administrative data offer a cost-efficient and powerful method for assessing outcomes for a large population-based national program. However, this approach is still at an early stage of development and needs to be further validated before it can be used at scale.

ObjectiveThe chronic obstructive pulmonary disease (COPD) integrated care pathway (ICP) programme was designed and implemented to ensure that the care for patients with COPD is comprehensive and integrated across different care settings from primary care to acute hospital and home. We evaluated the effectiveness of the ICP programme for patients with COPD.Design, setting and participantsA retrospective propensity score matched cohort study was conducted comparing differences between programme enrolees and propensity-matched non-enrolees in a Regional Health System in Singapore. Data on patients diagnosed with COPD who enrolled in the programme (n=95) and patients who did not enrol (n=6330) were extracted from the COPD registry and hospital administrative databases. Enrolees and non-enrolees were propensity score matched.Outcome measuresThe risk of COPD hospitalisations and COPD hospital bed days savings were compared between the groups using a difference-in-difference strategy and generalised estimating equation approach. Adherence with recommended care elements for the COPD-ICP group was measured quarterly at baseline and during a 2-year follow-up period.ResultsCompared with non-enrolees, COPD hospitalisation risk for ICP programme enrolees was significantly lower in year 2 (incidence rate ratio (IRR): 0.73; 95% CI 0.54 to 1.00). Similarly, COPD hospital bed days was significantly lower for enrolees in year 2 (IRR: 0.78; 95% CI 0.64 to 0.95). ICP programme patients had sustained improvements in compliance with all recommended care elements for patients with COPD. The overall all-or-none care bundle compliance rate had improved from 28% to 54%.ConclusionThe study concluded that the COPD-ICP programme was associated with reductions in COPD hospitalisation risk and COPD health utilisation in a 2-year follow-up period.

Background: Due to limited end-of-life discussions and the absence of palliative care, hospitalisations are frequent at the end of life among nursing home residents in Singapore, resulting in high health-care costs. Aim: Our objective was to evaluate the economic impact of Project Care at the End-of-Life for Residents in homes for the Elderly (CARE) programme on nursing home residents compared to usual end-of-life care. Design and settings/participants: Project CARE was introduced in seven nursing homes to provide advance care planning and palliative care for residents identified to be at risk of dying within 1 year. The cases consisted of nursing home residents enrolled in the Project CARE programme for at least 3 months. A historical group of nursing home residents not in any end-of-life care programme was chosen as the matched controls. Cost differences between the two groups were analysed over the last 3 months and final month of life. Results: The final sample comprised 48 Project CARE cases and 197 controls. Compared to the controls, the cases were older with more comorbidities and higher nursing needs. After risk adjustment, Project CARE cases demonstrated per-resident cost savings of SGD$7129 (confidence interval: SGD$4544–SGD$9714) over the last 3 months of life and SGD$3703 (confidence interval: SGD$1848–SGD$5557) over the last month of life (US$1 = SGD$1.3). Conclusion: This study demonstrated substantial savings associated with an end-of-life programme. With a significant proportion of the population in Singapore requiring nursing home care in the near future, these results could assist policymakers and health-care providers in decision-making on allocation of health-care resources.

Background: There is a shortage of health care professionals competent in diabetes management worldwide. Digital education is increasingly used in educating health professionals on diabetes. Digital diabetes self-management education for patients has been shown to improve patients’ knowledge and outcomes. However, the effectiveness of digital education on diabetes management for health care professionals is still unknown. Objective: The objective of this study was to assess the effectiveness and economic impact of digital education in improving health care professionals’ knowledge, skills, attitudes, satisfaction, and competencies. We also assessed its impact on patient outcomes and health care professionals’ behavior. Methods: We included randomized controlled trials evaluating the impact of digitalized diabetes management education for health care professionals pre- and postregistration. Publications from 1990 to 2017 were searched in MEDLINE, EMBASE, Cochrane Library, PsycINFO, CINAHL, ERIC, and Web of Science. Screening, data extraction and risk of bias assessment were conducted independently by 2 authors. Results: A total of 12 studies met the inclusion criteria. Studies were heterogeneous in terms of digital education modality, comparators, outcome measures, and intervention duration. Most studies comparing digital or blended education to traditional education reported significantly higher knowledge and skills scores in the intervention group. There was little or no between-group difference in patient outcomes or economic impact. Most studies were judged at a high or unclear risk of bias. Conclusions: Digital education seems to be more effective than traditional education in improving diabetes management–related knowledge and skills. The paucity and low quality of the available evidence call for urgent and well-designed studies focusing on important outcomes such as health care professionals’ behavior, patient outcomes, and cost-effectiveness as well as its impact in diverse settings, including developing countries. Published version

ObjectiveTo describe the end-of-life care preferences of individuals, and to examine the influence of age and gender on these preferences.Design, setting and participantsA retrospective cohort study was conducted. Participants included all adults (≥21 years old) (n=3380) who had completed a statement of their preferences as part of a national Advance Care Planning (ACP) programme in Singapore. Data were extracted from the national and Tan Tock Seng Hospital ACP database.Main measuresEnd-of-life care preferences were obtained from the ACP document and differentiated by health status (healthy, chronically ill or diagnosed with advanced illnesses). To analyse the data, descriptive statistics and logistic regression analysis were used.ResultsAcross healthy and chronically ill patients, the majority did not opt for cardiopulmonary resuscitation (CPR) or other life-sustaining measures. Among individuals with advanced illnesses, 94% preferred not to attempt CPR but 69% still preferred to receive some form of active medical treatment. Approximately 40% chose to be cared for, and to die at home. Age and sex significantly predict preferences in those with advanced illnesses. Older age (>=75 years) showed higher odds for home as preferred place of care (OR 1.52; 95% CI 1.23 to 1.89) and place of death (OR 1.29; 95% CI 1.03 to 1.61) and lower odds for CPR (OR 0.31; 95% CI 0.18 to 0.54) and full treatment (OR 0.32; 95% CI 0.17 to 0.62). Being female was associated with lower odds for home as preferred place of care (OR 0.69; 95% CI 0.57 to 0.84) and place of death (OR 0.70; 95% CI 0.57 to 0.85) and higher odds for full treatment (OR 2.35; 95% CI 1.18 to 4.68).ConclusionThe majority preferred to not proceed with life-sustaining treatments, but there was still a strong preference to receive some form of limited treatment. Better understanding of end-of-life care preferences through ACP can better guide end-of-life care programme planning, and resource allocation decisions.

Background: Cost of informal care constitutes an important component of total dementia care cost. It also reflects resource utilization by patients and caregivers. We aim to quantify the informal cost of care for mild to moderate dementia patients.Methods: We recruited 165 patient–caregiver dyads with mild to moderate dementia. Informal care burden was assessed using the Resource Utilization in Dementia (RUD)-Lite instrument. A generalized linear model was fitted for association between cost of informal care and cognitive impairment, taking into account patient demographics, disease factors, and use of paid domestic help. Marginal estimates were obtained from the model for the purpose of illustration and discussion.Results: Total hours of informal care by primary caregiver doubled in moderate dementia patients, with 57.9% having paid domestic help to assist in care. Functional factors and use of paid domestic help were significantly associated with informal care costs. Costs were consistently higher for patients without paid domestic help for mild- and moderate dementia.Conclusion: This study demonstrates the informal care costs of caring for mild–moderate dementia patients in Singapore, with the unique cost savings provided by live-in paid domestic help, and potentially may aid policy-makers in allocation of resources and support to caregivers.

BackgroundGlobally, healthcare systems face major challenges with medicines management and medication adherence. Medication adherence determines medication effectiveness and can be the single most effective intervention for improving health outcomes. In anticipation of growth in eHealth interventions worldwide, we explore the role of eHealth in the patients’ medicines management journey in primary care, focusing on personalisation and intelligent monitoring for greater adherence.DiscussioneHealth offers opportunities to transform every step of the patient’s medicines management journey. From booking appointments, consultation with a healthcare professional, decision-making, medication dispensing, carer support, information acquisition and monitoring, to learning about medicines and their management in daily life. It has the potential to support personalisation and monitoring and thus lead to better adherence. For some of these dimensions, such as supporting decision-making and providing reminders and prompts, evidence is stronger, but for many others more rigorous research is urgently needed.ConclusionsGiven the potential benefits and barriers to eHealth in medicines management, a fine balance needs to be established between evidence-based integration of technologies and constructive experimentation that could lead to a game-changing breakthrough. A concerted, transdisciplinary approach adapted to different contexts, including low- and middle-income contries is required to realise the benefits of eHealth at scale.

Objective We aim to determine whether healthcare costs for patients diagnosed with Type 2 Diabetes Mellitus (T2DM) are associated with the severity of diabetes complications as measured by the Diabetes Complication Severity Index (DCSI). Methods Retrospective cohort analysis was performed on a 2007 primary care cohort of T2DM patients. The DCSI is a 13-point scale, which comprises 7 categories of complications and their severity levels. Healthcare cost data from 2008 and 2009 were used as primary outcome. Inpatient and outpatient costs incurred for services consumed by patients within the provider network were included. Generalized linear model with log-link and gamma distribution was used to predict healthcare costs. Results Of the 59,767 T2DM patients, 2977 (5.0%) deaths occurred and 1336 (2.2%) were lost to follow up. Healthcare cost was strongly associated with increase in DCSI score. Compared to patients without complications, those with more complications (higher DCSI score) had an increased risk of higher healthcare costs. Risk ratio (RR) increased from 1.25 (95%CI: 1.19–1.32) for DCSI = 1 to 1.61 (1.51–1.72) for DCSI = 2; 2.10 (1.91–2.31) for DCSI = 3; 2.52 (2.21–2.87) for DCSI = 4 and 3.62 (3.09–4.25) for DCSI ≥ 5. As a continuous score, a one-point increase in the DCSI was associated with a cost increase of 27% (95%CI: 1.25–1.29). Conclusion The DCSI score is a useful tool for predicting direct healthcare costs. The DCSI can be used to triage high-risk patients for more focused secondary prevention interventions at primary care level, in a bid to lower overall healthcare costs.

Background and objective: The aim of this study was to estimate the direct medical costs of COPD in two public health clusters in Singapore from 2005 to 2009. Methods: Patients aged 40 years and over, who had been diagnosed with COPD, were identified in a Chronic Disease Management Data-mart. Annual utilization of health services in inpatient, specialist outpatient, emergency department and primary care settings was extracted from the Chronic Disease Management Data-mart. Trends in attributable costs, proportions of costs and health-care utilization were analyzed across each level of care. A weighted attribution approach was used to allocate costs to each health-care utilization episode, depending on the relevance of co-morbidities. Results: The mean total cost was approximately $9.9 million per year. Inpatient admissions were the major cost driver, contributing an average of $7.2 million per year. The proportion of hospitalization costs declined from 75% in 2005 to 68% in 2009. Based on the 5-year average, attendances at primary care clinics, emergency department and specialist clinics contributed 3%, 5% and 17%, respectively, of overall COPD costs. On average, 42% of the total cost burden was incurred for the medical management of COPD. The share of cost incurred for the treatment of conditions related and unrelated to COPD were 29% and 26%, respectively, of the total average costs. Conclusions: COPD is likely to represent a significant burden to the public health system in most countries. The findings are particularly relevant to understanding the allocation of health-care resources and informing appropriate cost containment strategies.

Self-monitoring of Blood Glucose (SMBG) is purported to improve glycaemic control, measured by glycosylated haemoglobin (HbA1c). The effectiveness of SMBG in type 2 diabetes mellitus (T2DM) is well-documented though no systematic review of the economic evidence surrounding the use of SMBG in T2DM has been performed.To perform a systematic review of economic evaluations of SMBG in T2DM patients.All adult patients suffering from T2DM were included. Outcomes of differing treatment groups, where specified, were also recorded. Studies which examined SMBG as an intervention to control blood glucose were considered. To be included, studies must have made a formal attempt to relate cost to outcome data in a cost-effectiveness or cost utility analysis.The main outcomes were in terms of cost-effectiveness and cost-utility.Extensive electronic searches were conducted. Searching was carried out, for the time period 1990 to January 2009, for full text papers and conference abstracts.Methodological quality of included studies was assessed by two reviewers using the standard critical appraisal tools from the JBI-Actuari (Joanna Briggs Institute-Analysis of Cost, Technology and Utilisation Assessment and Review Instrument). Included modelling studies were also assessed using the review criteria of economic models set out by Phillips and colleagues.Data from included studies were extracted using the JBI-Actuari extraction tool.Studies were grouped by outcome measure and summarised using tabular and narrative formats.Five studies met the review criteria. Three were model-based analyses assessing long-term cost-effectiveness of SMBG, all of which concluded that SMBG was cost-effective. Two further primary economic evaluations assessed short-term cost-effectiveness. Their results found SMBG to be associated with increased cost and no significant reduction in HbA1c. The studies examined subgroups in terms of their treatment protocols and SMBG was considered more likely to be cost-effective in drug and insulin treated groups compared to diet and exercise groups.Economic evidence surrounding SMBG in T2DM remains unclear. For the most part, included studies found SMBG to be cost-effective though analyses are extremely sensitive to relative effects, time-frame of analyses and model assumptions. Whilst large uncertainty exists, SMBG may be cost-effective in certain subgroups e.g. drug and insulin-treated patients.No strong evidence to recommend the regular use of SMBG in well-controlled diabetes patients, treated only with diet and exercise programmes, exists. The evidence does offer support for SMBG in drug and insulin treated T2DM. It is recommended that clinicians select appropriate patients for SMBG, from these groups, based on their domain expertise.Large-scale prospective RCTs of SMBG, particularly in drug and insulin treated patients, with well-conducted economic evaluations performed alongside them, will enable a more accurate estimation of the cost-effectiveness of SMBG. The optimal frequency and administration of SMBG is still unknown and is another area that warrants further research.

This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. Woan Shin Tan and colleagues illustrate progress towards UHC and its monitoring and evaluation in Singapore. Please see later in the article for the Editors' Summary

Hispanic populations. Analyze prevalence, incidence, new patient age, therapy adherence, inferred disease severity, and inferred disease progression. METHODS: Catalina HealthTM receives a nationally representative sample of pharmacy data containing 40% of all US retail prescription volume and 130 million unique patient ID’s. The data is HIPAA compliant, updated daily, longitudinal, and not projected. Select a cohort of patients (40% random sample) filling diabetes scripts in the 1st quarter of 2007 in zip codes with low ( 3%) or high (25% ) Hispanic population based on US census data. Overall the high group averages 50% Hispanic. Use a 1 year look-back period, and follow the patient cohort for 4 years. Consider patients adherent when Proportion of Days Covered (PDC) 80%. RESULTS: Diabetes patients available for analysis varied by metric: prevalence (478k), incidence (58k), adherence (31K). Logistic regression adjusting for covariates, or ANCOVA models are fit depending upon the metric. Covariates include average age of all patients visiting the pharmacy, proportion female, state, retailer chain, median income of the pharmacy’s zip code, and rural zip code designation. Patients in high Hispanic populations have 26% greater prevalence of diabetes (OR 1.26, p-value 0.0001), and 25% greater incidence (OR 1.25, p-value 0.0001). Additionally, they are 20% less likely to be adherent to therapy after 24 months (OR 0.80, p-value 0.0005), and 17% less likely after 48 months (OR 0.83, p-value 0.0055). CONCLUSIONS: High Hispanic populations have significantly higher incidence and prevalence of diabetes. They are also significantly less adherent to therapy. No differences are seen in age of new diabetes patients, inferred disease severity, or inferred disease progression. Culturally relevant diabetes education should be provided in US geographies with high Hispanic populations.

Background The study objective was to compare physical function documented in the medical records with interview data, and also to evaluate hospital mortality predictions using pre-admission and on-admission functional status derived from these two data sources. Methods A prospective cohort study of 1402 subjects aged 65 years and older to the general medicine department of an acute care hospital was conducted. Patient-reported pre-admission and on-admission functional status for impairment in any of the five activities of daily living (ADLs) items (feeding, dressing, grooming, toileting and bathing), transferring and walking, were compared with those extracted from the medical records. For the purpose of mortality prediction, pre-admission and on-admission impairment in transferring from the two data sources were included in separate multivariable logistic regression models. We used a variable selection method that combines bootstrap resampling with stepwise backward elimination. Results For all ADL categories, the agreement between the data sources was good for pre-admission functional status (k: 0.53–0.75) but poor for on-admission status (k: 0.18–0.31). On-admission impairment was higher in the medical records than at interview for all basic ADLs. Using interview data as the gold standard, although sensitivity for pre- and on-admission ADLs was high (59–93%), specificity for on-admission status was poor (30–37%). The pre-admission models using interview data predicted mortality better than the model using medical records (c-statistic: 0.83 versus 0.82). Similar results were found for models incorporating on-admission functional status (c-statistic: 0.84 versus 0.81). However, the differences between the four models were not statistically significant. Conclusion Medical records can be a good source for pre-admission functional status but on-admission functional impairment was over-reported in the medical records. The discriminatory power of the hospital mortality prediction model was significantly improved with the incorporation of functional status information but it was not significantly affected by their time reference or source of data.

Tan WS, Heng BH, Chua KS, Chan KF. Factors predicting inpatient rehabilitation length of stay of acute stroke patients in Singapore. Objective To determine the predictors of hospital length of stay (LOS) of stroke patients at the point of admission. Design A retrospective cohort study. Setting An acute hospital rehabilitation center in Singapore. Participants Stroke patients (N=491) admitted between March 2005 and December 2006. Interventions None. Main Outcome Measures Rehabilitation LOS was calculated as the total number of rehabilitation days before discharge. We measured the functional status of patients by using the Functional Independence Measure (FIM). Results The median LOS was 29 days (mean = 30.8d). Independent clinical and sociodemographic characteristics found to significantly predict rehabilitation LOS were FIM motor score at admission, the presence of more than 3 comorbid conditions at admission, living with nonimmediate relatives before admission, and the hospital subsidy status of the patient. In particular, the admission FIM motor score explained 43% of the variation in LOS and decreased the LOS by approximately 1.1 days for each 1-point increase in score. Conclusion Patients' socioeconomic status and family structure was found to influence LOS and should be considered in allocating resources and determining treatment need. The extent of motor function of patients at admission is an important factor influencing rehabilitation LOS and is a useful tool for facilitating rehabilitation resource planning for stroke patients.

Introduction The treatment of chronic obstructive pulmonary disease (COPD) involves different care providers across care sites. This fragmentation of care increases the morbidity and mortality burden, as well as acute health services use. The COPD-Integrated Care Pathway (ICP) was designed and implemented to integrate the care across different sites from primary care to acute hospital and home. It aims to reduce the prevalence of COPD among the population in the catchment, reduce risk of hospital admissions, delay or prevent the progression of the disease and reduce mortality rate by adopting a coordinated and multidisciplinary approach to the management of the patients’ medical conditions. This study on the COPD-ICP programme is undertaken to determine the impact on processes of care, clinical outcomes and acute care utilisation. Methods and analysis This will be a retrospective, pre-post, matched-groups study to evaluate the effectiveness of the COPD-ICP programme in improving clinical outcomes and reducing healthcare costs. Programme enrolees (intervention group) and non-enrolees (comparator group) will be matched using propensity scores. Administratively, we set 30% as our target for proportion admission difference between programme and non-programme patients. A sample size of 62 patients in each group will be needed for statistical comparisons to be made at 90% power. Adherence with recommended care elements will be measured at baseline and quarterly during 1-year follow-up. Risk of COPD-related hospitalisations as primary outcome, healthcare costs, disease progression and 1-year mortality during 1-year follow-up will be compared between the groups using generalised linear regression models. Ethics and dissemination This protocol describes the implementation and proposed evaluation of the COPD-ICP programme. The described study has received ethical approval from the NHG Domain Specific Review Board (DSRB Ref: 2013/01200). Results of the study will be reported through peer-review publications and presentations at healthcare conferences.