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Introduction The burden of chronic kidney disease (CKD) is rising globally including in Singapore. Primary care is the first point of contact for most patients with early stages of CKD. However, several barriers to optimal CKD management exist. Knowing healthcare professionals’ (HCPs) perspectives is important to understand how best to strengthen CKD services in the primary care setting. Integrating a theory-based framework, we explored HCPs’ perspectives on the facilitators of and barriers to CKD management in primary care clinics in Singapore. Methods In-depth interviews were conducted on a purposive sample of 20 HCPs including 13 physicians, 2 nurses and 1 pharmacist from three public primary care polyclinics, and 4 nephrologists from one referral hospital. Interviews were audio recorded, transcribed verbatim and thematically analyzed underpinned by the Theoretical Domains Framework (TDF) version 2. Results Numerous facilitators of and barriers to CKD management identified. HCPs perceived insufficient attention is given to CKD in primary care and highlighted several barriers including knowledge and practice gaps, ineffective CKD diagnosis disclosure, limitations in decision-making for nephrology referrals, consultation time, suboptimal care coordination, and lack of CKD awareness and self-management skills among patients. Nevertheless, intensive CKD training of primary care physicians, structured CKD-care pathways, multidisciplinary team-based care, and prioritizing nephrology referrals with risk-based assessment were key facilitators. Participants underscored the importance of improving awareness and self-management skills among patients. Primary care providers expressed willingness to manage early-stage CKD as a collaborative care model with nephrologists. Our findings provide valuable insights to design targeted interventions to enhance CKD management in primary care in Singapore that may be relevant to other countries. Conclusions The are several roadblocks to improving CKD management in primary care settings warranting urgent attention. Foremost, CKD deserves greater priority from HCPs and health planners. Multipronged approaches should urgently address gaps in care coordination, patient-physician communication, and knowledge. Strategies could focus on intensive CKD-oriented training for primary care physicians and building novel team-based care models integrating structured CKD management, risk-based nephrology referrals coupled with education and motivational counseling for patients. Such concerted efforts are likely to improve outcomes of patients with CKD and reduce the ESKD burden.

BACKGROUND Cognition generally declines gradually over time due to progressive degeneration of the brain, leading to dementia and eventual loss of independent functions. Cognition in the six domains (perceptual motor, executive function, complex attention, learning and memory, social cognition and language) varies in their rate of regression. Current modality of cognitive assessment using neuropsychological, questionnaire-based such as the Montreal Cognitive Assessment (MoCA) has its limitations and is influenced by age. Virtual reality (VR) has been introduced as a potential alternative tool to assess cognition. A novel fully immersive automated VR system (CAVIRE) has been developed to assess the six cognitive domains. As cognition is associated with age, VR performance is postulated to vary with age using this system. OBJECTIVE This study aimed to evaluate the VR performance of cognitively healthy adults using the CAVIRE system based on its automated scoring matrix and completion time. METHODS Conducted in a public primary care clinic in Singapore, the study recruited 25 multi-ethnic Asian adults in each of the age groups in years: 1. 35-44; 2. 45-54; 3. 55-64 and 4. 65-74. Their eligibility included a MoCA score of 26 or higher to reflect normal cognition and understanding the automated English instructions in the CAVIRE system. They completed common daily activities from brushing teething to shopping across 13 virtual segments. Their performances were automatically evaluated and computed using cognitive domain score matrix and completion time of the VR tasks. These VR performance indices were compared across the age groups using a one-way ANOVA, F-test of the hypothesis, followed by pair-wise comparisons in the event of a significant F-test (p RESULTS One participant dropped out from Group 1. The demographic characteristics of 99 participants were similar across the 4 age groups. Overall, younger participants in Groups 1 and 2 attained higher VR performance scores and shorter completion time using the CAVIRE system, compared to those in Groups 3 and 4 in every cognitive domain (all p CONCLUSIONS The CAVIRE VR performance scores and completion time significantly differ between the younger and older Asian participants with normal cognition. Enhancements to the system are needed to establish the age-group specific normal performance indices. CLINICALTRIAL INTERNATIONAL REGISTERED REPORT RR2-10.3389/fnagi.2020.604670

IntroductionPatient decision-aids (PDAs) support patients in selecting evidence-based treatment options. PDA is useful only if the user understands the content to make personalised decisions. Cultural adaptation is a process of adjusting health messages so that the information is accurate, relevant and understandable to users from a different population. A PDA has been developed to assist Malaysian patients with secondary drug failure to initiate insulin therapy to control their type 2 diabetes mellitus (T2DM). Likewise, patients with T2DM in neighbouring Singapore face similar barriers in commencing insulin treatment, which a PDA may facilitate decision-making in selecting personalised therapy.ObjectiveThe study aimed to explore the views and perceptions of Singaporean primary care providers on the Malaysia PDA to initiate insulin therapy and described the cultural adaptation process used in the design and development of a new PDA, which would be trialled in a Singapore primary healthcare institution.MethodQualitative research method was deployed to conduct one-to-one in-depth interviews of the healthcare providers at the trial site (SingHealth Polyclinics—SHP), including six primary care physicians and four nurses to gather their views and feedbacks on the Malaysian PDA. The interviews were transcribed, audited and analysed (standard content analysis) to identify themes relating to the content, layout, concerns of the original PDA and suggestions to the design of the new SHP PDA.ResultsCultural adaptation of the new PDA includes change to the overall design, graphics (including pictograms), presentation styles, additional contextualised content (personalisation, subheadings, cost and treatment option), modified phrasing of the subtitles and concerns (choice of words) relevant to the new users.ConclusionA PDA on insulin therapy underwent cultural adaptation before its implementation in another population in a neighbouring country. Its relevance and effectiveness will be evaluated in future research.

ObjectiveTo outline the facilitators and barriers to patients’ self-management of predialysis chronic kidney disease (CKD).DesignQualitative.SettingThree polyclinics in a public primary care institution in Singapore.Participants20 patients entered and completed the study. Inclusion criteria were: (1) English speaking, (2) aged 40 years and above, (3) identified by clinical coding as ‘DM (diabetes mellitus) nephropathy-overt’ and ‘DM nephropathy-incipient’, by their physicians in the polyclinic, with an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2 (based on electronic health records) and (4) aware of their CKD illness. Exclusion criteria were: (1) receiving dialysis or had received a kidney transplant, (2) suffered from any visual, auditory or cognitive impairment which could hinder their ability to participate in the study or (3) pregnant.ResultsWe found that the major barriers to CKD management were a lack of knowledge and awareness of CKD, a passive attitude toward self-management and insufficient patient-physician communication. Major facilitators included patient trust and satisfaction with the physician and family support. Many patients reported that there was an overload of information and too little guidance on how to manage their condition, especially regarding dietary recommendations.ConclusionWe identified several barriers and facilitators to the management of predialysis CKD among patients. A multi-pronged approach for raising CKD awareness is required: improving patient-physician communication, implementing CKD workshops and home-visits and disseminating accurate online information about CKD. Strategies should also focus on increasing patient engagement and optimising family support by involving family members in patients’ care. Furthermore, clear dietary recommendations and patient-specific advice are needed to empower patients to manage their own condition.