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Objectives This study aims to examine the impact of COVID-19 measures on wellbeing and self-management in medically vulnerable non-COVID patients and their views of novel modalities of care in Singapore. Methods Patients with cardiovascular disease (CVD), respiratory disease, chronic kidney disease, diabetes and cancer were recruited from the SingHealth cluster and national cohort of older adults. Data on demographics, chronic conditions and perceived wellbeing were collected using questionnaire. We performed multivariable regression to examine factors associated with perceived wellbeing. Qualitative interviews were conducted to elicit patient's experience and thematically analyzed. Results A total of 91 patients participated. Male patients compared with female patients perceived a lower impact of the pandemic on subjective wellbeing. Patients with CVD compared to those having conditions other than CVD perceived a lower impact. Impacts of the pandemic were primarily described in relation to emotional distress and interference in maintaining self-care. Hampering of physical activity featured prominently, but most did not seek alternative ways to maintain activity. Despite general willingness to try novel care modalities, lack of physical interaction and communication difficulties were perceived as main barriers. Discussion Findings underline the need to alleviate emotional distress and develop adaptive strategies to empower patients to maintain wellbeing and self-care.

BACKGROUND Several countries around the world have implemented multicomponent interventions to enhance primary care, as a way of strengthening their health systems to cope with an aging chronically ill population and rising costs. Some of these efforts have included technology-based enhancements as one of the features to support the overall intervention, but their details and impacts have not been explored. OBJECTIVE This study aimed to identify the role of digital/health technologies within wider multifeature interventions that are aimed at enhancing primary care, and to describe their aims and stakeholders, types of technologies used, and potential impacts. METHODS A systematic review was performed following Cochrane guidelines. An electronic search, conducted on May 30, 2019, was supplemented with manual and grey literature searches in December 2019, to identify multicomponent interventions that included at least one technology-based enhancement. After title/abstract and full text screening, selected articles were assessed for quality based on their study design. A descriptive narrative synthesis was used for analysis and presentation of the results. RESULTS Of 37 articles, 14 (38%) described the inclusion of a technology-based innovation as part of their multicomponent interventions to enhance primary care. The most commonly identified technologies were the use of electronic health records, data monitoring technologies, and online portals with messaging platforms. The most common aim of these technologies was to improve continuity of care and comprehensiveness, which resulted in increased patient satisfaction, increased primary care visits compared to specialist visits, and the provision of more health prevention education and improved prescribing practices. Technologies seem also to increase costs and utilization for some parameters, such as increased consultation costs and increased number of drugs prescribed. CONCLUSIONS Technologies and digital health have not played a major role within comprehensive innovation efforts aimed at enhancing primary care, reflecting that these technologies have not yet reached maturity or wider acceptance as a means for improving primary care. Stronger policy and financial support, and advocacy of key stakeholders are needed to encourage the introduction of efficient technological innovations, which are backed by evidence-based research, so that digital technologies can fulfill the promise of supporting strong sustainable primary care.

Introduction: Singapore’s ageing population is likely to see an increase in chronic eye conditions in the future. This study aimed to estimate the burden of eye diseases among resident Singaporeans stratified for age and ethnicity by 2040. Materials and Methods: Prevalence data on myopia, epiretinal membrane (ERM), retinal vein occlusion (RVO), age macular degeneration (AMD), diabetic retinopathy (DR), cataract, glaucoma and refractive error (RE) by age cohorts and educational attainment from the Singapore Epidemiology of Eye Diseases (SEED) study were applied to population estimates from the Singapore population model. Results: All eye conditions are projected to increase by 2040. Myopia and RE will remain the most prevalent condition, at 2.393 million (2.32 to 2.41 million) cases, representing a 58% increase from 2015. It is followed by cataract and ERM, with 1.33 million (1.31 to 1.35 million), representing an 81% increase, and 0.54 million (0.53 to 0.549 million) cases representing a 97% increase, respectively. Eye conditions that will see the greatest increase from 2015 to 2040 in the Chinese are: DR (112%), glaucoma (100%) and ERM (91.4%). For Malays, DR (154%), ERM (136%), and cataract (122%) cases are expected to increase the most while for Indians, ERM (112%), AMD (101%), and cataract (87%) are estimated to increase the most in the same period. Conclusion: Results indicate that the burden for all eye diseases is expected to increase significantly into the future, but at different rates. These projections can facilitate the planning efforts of both policymakers and healthcare providers in the development and provision of infrastructure and resources to adequately meet the eye care needs of the population. By stratifying for age and ethnicity, high risk groups may be identified and targeted interventions may be implemented. Key words: Ophthalmology, System dynamics

Introduction: In the context of rapid population ageing and the increase in number of activity of daily living (ADL) limitations with age, the number of older persons requiring human assistance in Singapore is likely to grow. To promote informed planning for the needs of these elderly, we project the number of resident Singaporeans 60 years of age and older with 1 or more ADL limitations requiring human assistance through 2030. Materials and Methods: The proportion of community-dwelling older adults with ADL limitations requiring human assistance, stratified by gender and age group, was calculated utilising a recent nationally-representative survey of older Singaporeans. The proportion of older adults in nursing homes with ADL limitations was estimated based on available literature. Together, these prevalence estimates were applied to a simulation of the future population of older adults in Singapore to derive an estimate of the number of individuals with ADL limitations requiring human assistance through 2030. Results: By 2030, the number of resident Singaporeans aged 60 years or older with 1 or more ADL limitations requiring human assistance is projected to be 82,968 persons (7% of the total population aged 60 years or older). Of this number, 38,809 (47%) are estimated to have 1 or 2 ADL limitations, and 44,159 (53%) are estimated to have 3 or more. Conclusion: The number of elderly Singaporeans with activity limitations is expected grow rapidly from 31,738 in 2010 to 82,968 in 2030. Estimates of the number of older individuals with ADL limitations requiring human assistance are of value for policymakers as well as acute and long-term care capacity planners as they seek to meet demand for health and social services in Singapore. Key words: Ageing, Activities of daily living, Forecasting, Long-term care, Singapore

Introduction: The Short Portable Mental Status Questionnaire (SPMSQ) is a brief cognitive screening instrument, which is easy to use by a healthcare worker with little training. However, the validity of this instrument has not been established in Singapore. Thus, the primary aim of this study was to determine the diagnostic performance of SPMSQ for screening dementia among patients attending outpatient cognitive assessment clinics and to assess whether the appropriate cut-off score varies by patient’s age and education. A secondary aim of the study was to map the SPMSQ scores with Mini-Mental State Examination (MMSE) scores. Materials and Methods: SPMSQ and MMSE were administered by a trained interviewer to 127 patients visiting outpatient cognitive assessment clinics at the Singapore General Hospital, Changi General Hospital and Tan Tock Seng Hospital. The geriatricians at these clinics then diagnosed these patients with dementia or no dementia (reference standard). Sensitivity and specificity of SPMSQ with different cut-off points (number of errors) were calculated and compared to the reference standard using the Receiver Operator Characteristic (ROC) analysis. Correlation coefficient was also calculated between MMSE and SPMSQ scores. Results: Based on the ROC analysis and a balance of sensitivity and specificity, the appropriate cut-off for SPMSQ was found to be 5 or more errors (sensitivity 78%, specificity 75%). The cut-off varied by education, but not by patient’s age. There was a high correlation between SPMSQ and MMSE scores (r = 0.814, P

Singapore is one of the fastest-aging countries in the world, and the demand for acute hospital care for older adults is expected to triple in the next 25 years. Hence, it is crucial to understand the opportunities in reducing potentially avoidable bed days (PABD), which are days spent in acute hospitals delivering only non-acute services. We aimed to access the prevalence, causes and consequences of PABD among geriatric patients.We examined all hospitalizations from 1 August through 31 December 2013 in the geriatric wards of an acute hospital in Singapore. PABD were identified using a modified Appropriateness Evaluation Protocol. Non-acute services were classified as subacute care, rehabilitative care, long-term care or social care. Hospitalization patterns were determined based on the presence or absence of non-acute services, and multinomial logistic regression was used to determine predictors of different patterns.Of the 273 bed days used by 254 patients, 49% were potentially avoidable. The most common non-acute services provided were rehabilitative care (19%), subacute care (12%) and long-term care (8%). New acute issues arose after the admission conditions subsided in 2.4% of hospitalizations, 61% of which were nosocomial infections. Being socially at risk as assessed on admission predicted the development of new acute issues (sensitivity = 62%; specificity = 88%).In the present study, almost half of the bed days were potentially avoidable. New acute issues can arise after PABD, which are dangerous to these frail older adults. Proactive discharge planning and increasing access to intermediate and long-term care services are required to reduce PABD. Geriatr Gerontol Int 2017; 17: 1575-1583.

In the context of rapid population ageing and the increase in number of activity of daily living (ADL) limitations with age, the number of older persons requiring human assistance in Singapore is likely to grow. To promote informed planning for the needs of these elderly, we project the number of resident Singaporeans 60 years of age and older with 1 or more ADL limitations requiring human assistance through 2030.The proportion of community-dwelling older adults with ADL limitations requiring human assistance, stratified by gender and age group, was calculated utilising a recent nationally-representative survey of older Singaporeans. The proportion of older adults in nursing homes with ADL limitations was estimated based on available literature. Together, these prevalence estimates were applied to a simulation of the future population of older adults in Singapore to derive an estimate of the number of individuals with ADL limitations requiring human assistance through 2030.By 2030, the number of resident Singaporeans aged 60 years or older with 1 or more ADL limitations requiring human assistance is projected to be 82,968 persons (7% of the total population aged 60 years or older). Of this number, 38,809 (47%) are estimated to have 1 or 2 ADL limitations, and 44,159 (53%) are estimated to have 3 or more.The number of elderly Singaporeans with activity limitations is expected grow rapidly from 31,738 in 2010 to 82,968 in 2030. Estimates of the number of older individuals with ADL limitations requiring human assistance are of value for policymakers as well as acute and long-term care capacity planners as they seek to meet demand for health and social services in Singapore.

BACKGROUND More than 50,000 male patients received hormonal therapy for metastatic prostate carcinoma in 1995. Nonsteroidal antiandrogens, such as flutamide, when used in conjunction with castration, are effective in prolonging the time to progression of disease and survival. Only one-third of newly diagnosed patients with metastatic prostate carcinoma receive flutamide. Physicians may be reluctant to prescribe flutamide because of quality of life, toxicity, and cost considerations. METHODS Physician focus groups evaluated quality of life factors for metastatic prostate cancer. RESULTS Using quality of life estimates with the National Cancer Institute's (NCI) 0036 clinical trial results, our revised model of flutamide use predicted that, for minimal disease, survival increased by 4.33 quality adjusted months (QAMs) at an incremental cost of $25,000 per quality adjusted life year (QALY) saved and for severe disease, survival increased by 4.11 QAM at a cost of $18,000 per QALY saved. However, if quality of life estimates are used in conjunction with the Prostate Cancer Trialists' Collaborative Group (PCTCG) meta-analysis estimates, survival increased by 2.1 QAM at an incremental cost of $41,000 per QALY saved for persons with severe disease and increased by 2.6 QAM at an incremental cost of $53,700 per QALY saved for persons with minimal disease. CONCLUSIONS Using NCI 0036 trial data, flutamide has an incremental cost-effectiveness more favorable than most therapies, while estimates based on the PCTCG found a less favorable outcome for the drug. Concerns about out-of-pocket expenditures and efficacy limit flutamide utilization; quality of life considerations are less cogent. Cancer 1996;77:1854-61.

Background and Purpose— The diversity of available outcome measures for acute stroke trials is challenging and implies that the scales may be imperfect. To assist researchers planning trials and to aid interpretation, this article reviews and makes recommendations on the available choices of scales. The aim is to identify an approach that will be universally accepted and that should be included in most acute trials, without seeking to restrict options for special circumstances. Methods— The article considers outcome measures that have been widely used or are currently advised. It examines desirable properties for outcome measures such as validity, relevance, responsiveness, statistical properties, availability of training, cultural and language issues, resistance to comorbidity, as well as potential weaknesses. Tracking and agreement among outcomes are covered. Results— Typical ranges of scores for the common scales are described, along with their statistical properties, which in turn influence optimal analytic techniques. The timing of recovery on scores and usual practice in trial design are considered. Conclusions— The preferred outcome measure for acute trials is the modified Rankin Scale, assessed at 3 months after stroke onset or later. The interview should be conducted by a certified rater and should involve both the patient and any relevant caregiver. Incremental benefits at any level of the modified Rankin Scale may be acceptable. The modified Rankin Scale is imperfect but should be retained in its present form for comparability with existing treatment comparisons. No second measure should be required, but correlations with supporting scales may be used to confirm consistency in direction of effects on other measures.

BACKGROUND: Warfarin reduces the risk of ischemic stroke in patients (pts) with atrial fibrillation (AF) by >50% compared to aspirin in clinical trials, but is underutilized and can be difficult to manage. METHODS: REAL-AF is an observational registry that consists of retrospective and prospectively-enrolled pts with newly-diagnosed nonvalvular AF from 250 community-based US practices. This interim analysis focuses only on the retrospective arm, with six months of follow-up data. For all pts, baseline demographics were collected. Healthcare utilization, time to reach and time within target therapeutic range (TTR) were analyzed in pts on warfarin. For those not on warfarin, reasons for not prescribing were collected by selecting from a list of commonly-cited reasons. Multivariate models were used to assess factors associated with use of anticoagulation. RESULTS: Of 961pts observed to date, the mean age was 71.2±12.5 years; 51.5% male; 71.8% (654/911) white. Of the 68.4% (657/961) that received warfarin, 71% (3810/5356) of INR tests were conducted in the physician's office with about half (2501/5356) requiring further action such as a dose adjustment, more frequent monitoring, or physician or hospital visit. On average, pts had 13 INR tests (5070/390) and 4.5 dose adjustments (972/216) over a 6-month period. Mean TTR was 52.1% (N=348 pts). Median time to reach stable therapeutic range (3 consecutive INRs between 2.0 and 3.0) was 17.9 weeks (N=339 pts). High variability of INR values was associated with higher healthcare utilization (r=0.25, p=0.004). Physician-perceived “low stroke risk” (45%; 136/304) and “high bleed risk” (22%; 68/304) were the most common reasons for no anticoagulation. Excessive fall risk (OR 0.069, 95% CI 0.036-0.133) and full-time employment (OR 0.61, 95% CI 0.40-0.94) were significant predictors for warfarin non-use, based upon multivariate analysis. CONCLUSIONS: Non-therapeutic INR values and warfarin dose adjustments are common among newly diagnosed AF pts who have little or no previous exposure to anticoagulation therapy. From this retrospective analysis it appears that the current use of anticoagulation therapy in pts with AF is not optimal.

The aim of this study was to compare outcomes in older individuals receiving drug-eluting stents (DES) and bare-metal stents (BMS).Comparative effectiveness of DES relative to BMS remains unclear.Outcomes were evaluated in 262,700 patients from 650 National Cardiovascular Data Registry sites during 2004 to 2006 with procedural registry data linked to Medicare claims for follow-up. Outcomes including death, myocardial infarction (MI), revascularization, major bleeding, stroke, death or MI, death or MI or revascularization, and death or MI or stroke were compared with estimated cumulative incidence rates with inverse probability weighted estimators and Cox proportional hazards ratios.The DES were implanted in 217,675 patients and BMS were implanted in 45,025. At 30 months, DES patients had lower unadjusted rates of death (12.9% vs. 17.9%), MI (7.3 of 100 patients vs. 10.0 of 100 patients), and revascularization (23.0 of 100 patients vs. 24.5 of 100 patients) with no difference in stroke or bleeding. After adjustment, DES patients had lower rates of death (13.5% vs. 16.5%, hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.72 to 0.79, p0.001) and MI (7.5 of 100 patients vs. 8.9 of 100 patients, HR: 0.77, 95% CI: 0.72 to 0.81, p0.001), with minimal difference in revascularization (23.5 of 100 patients vs. 23.4 of 100 patients; HR: 0.91, 95% CI: 0.87 to 0.96), stroke (3.1 of 100 patients vs. 2.7 of 100 patients, HR: 0.97, 95% CI: 0.88 to 1.07), or bleeding (3.4 of 100 patients vs. 3.6 of 100 patients, HR: 0.91, 95% CI: 0.84 to 1.00). The DES survival benefit was observed in all subgroups analyzed and persisted throughout 30 months of follow-up.In this largest ever real-world study, patients receiving DES had significantly better clinical outcomes than their BMS counterparts, without an associated increase in bleeding or stroke, throughout 30 months of follow-up and across all pre-specified subgroups.

Health care providers frequently cite concerns about cardiovascular safety of the triptans as a barrier to their use. In 2002, the American Headache Society convened the Triptan Cardiovascular Safety Expert Panel to evaluate the evidence on triptan-associated cardiovascular risk and to formulate consensus recommendations for making informed decisions for their use in patients with migraine.To summarize the evidence reviewed by the Triptan Cardiovascular Safety Expert Panel and their recommendations for the use of triptans in clinical practice.The Triptan Cardiovascular Safety Expert Panel was composed of a multidisciplinary group of experts in neurology, primary care, cardiology, pharmacology, women's health, and epidemiology.An exhaustive search of the relevant published literature was reviewed by each panel member in preparation for an open roundtable meeting. Pertinent issues (eg, cardiovascular pharmacology of triptans, epidemiology of cardiovascular disease, cardiovascular risk assessment, migraine) were presented as a prelude to group discussion and formulation of consensus conclusions and recommendations. Follow-up meetings were held by telephone.(1) Most of the data on triptans are derived from patients without known coronary artery disease. (2) Chest symptoms occurring during use of triptans are generally nonserious and are not explained by ischemia. (3) The incidence of serious cardiovascular events with triptans in both clinical trials and clinical practice appears to be extremely low. (4) The cardiovascular risk-benefit profile of triptans favors their use in the absence of contraindications.

To the Editor.— Longstreth et al 1 demonstrate the benefit of resuscitation in elderly patients. I was concerned that some of the data presented did not agree with information published previously from the same center. In particular, the proportion of patients presenting with an initial rhythm of ventricular fibrillation—37%—is far lower than before. Between April 1976 and August 1977, 63% of attempted resuscitations in Seattle were for ventricular fibrillation. 2 Last year, in a review of the "Seattle perspective," Greene 3 cited research showing that 75% of resuscitation attempts were for ventricular fibrillation. This latter work related to the period 1971 through 1987 and therefore includes many of the cases reported by Longstreth et al. In Britain, the most complete audits of paramedic systems have shown that ventricular fibrillation accounts for about 35% of initial rhythms. We have compared these figures with the previously reported American figure of about 75%