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Abstract Background Telehealth, including video consultation (VC), has become prevalent during the COVID-19 pandemic. However, the experience and concern of women using VC for postpartum care has yet to be adequately studied but is crucial for their adoption. The study aimed to assess the experience and attitude of postpartum mothers (PPM) towards using VC as a novel model of care delivery and the factors that could potentially affect their adoption. Method Data were gathered from PPM participating in VC using Zoom platform for postpartum care using mixed method. In-depth interviews (IDI) of twenty-five PPM were audio-recorded, transcribed verbatim and audited for accuracy. Thematic analysis was conducted to identify themes relating to perceived threat, usefulness, ease of use, and attitudes toward using VC in postpartum care. The themes are reported based on the “Health Information Technology Acceptance Model” framework. Preliminary quantitative data on the acceptability of VC were collected using structured surveys. Results PPMs valued convenience, accessibility, and personalised care VC offered to address their immediate postpartum concerns. They perceived VC as suitable for seeking medical opinions, improving confidence in parent crafting, and providing better care access. They recognised the lack of physical examination as a major limitation in VC and proposed a hybrid postpartum care model, combining VC and in-person consultation to cater to individual needs and preferences. PPMs alluded to trust in the care providers, flexibility in VC appointment timings and enhanced interface of remote platforms as enablers for VC adoption. Preliminary quantitative data shows that PPMs found VC saved time (100%), energy (98%), and money (90%) and was appropriate (94%), easy to use (96%), acceptable (96%) for postpartum care. Conclusion PPMs favoured combining VC and in-person consultation to mitigate their concerns and personalise their care needs.

Abstract Inhaled corticosteroid (ICS) is the mainstay therapy for asthma, but general adherence is low. There is a paucity of real-world inhaler prescribing and adherence data from Asia and at the population level. To address these gaps, we performed a real-world data analysis of inhaler prescribing pattern and adherence in a multi-ethnic Asian asthma cohort and evaluated the association with asthma outcomes. We performed a retrospective analysis of adult asthma patients (aged ≥18 years) treated in the primary and specialist care settings in Singapore between 2015 to 2019. Medication adherence was measured using the medication possession ratio (MPR), and categorised into good adherence (MPR 0.75-1.2), poor adherence (MPR 0.75) or medication oversupply (MPR > 1.2). All statistical analyses were performed using R Studio. 8023 patients, mean age 57 years, were evaluated between 2015 and 2019. Most patients were receiving primary care (70.4%) and on GINA step 1–3 therapies (78.2%). ICS-long-acting beta-2 agonist (ICS-LABA) users increased over the years especially in the primary care, from 33% to 52%. Correspondingly, inpatient admission and ED visit rates decreased over the years. Between 2015 and 2019, the proportion of patients with poor adherence decreased from 12.8% to 10.5% (for ICS) and from 30.0% to 26.8% (for ICS-LABA) respectively. Factors associated with poor adherence included minority ethnic groups (Odds ratio of MPR 0.75–1.2: 0.73–0.93; compared to Chinese), presence of COPD (OR 0.75, 95% CI 0.59–0.96) and GINA step 4 treatment ladder (OR 0.71, 95% CI 0.61–0.85). Factors associated with good adherence were male gender (OR 1.14, 95% CI 1.01–1.28), single site of care (OR 1.22 for primary care and OR 1.76 for specialist care), GINA step 2 treatment ladder (OR 1.28, 95% CI 1.08–1.50). Good adherence was also associated with less frequent inpatient admission (OR 0.91, 95% CI 0.84–0.98), greater SABA overdispensing (OR 1.66, 95% CI 1.47–1.87) and oral corticosteroids use (OR 1.10, 95% CI 1.05–1.14). Inhaled corticosteroid (ICS) adherence has improved generally, however, poor adherence was observed for patients receiving asthma care in both primary and specialist care, and those from the minority ethnicities.

Abstract Background Chronic kidney disease (CKD) poses a global health challenge with high morbidity and mortality rates. Early detection and prompt intervention are critical in preventing progression to end-stage kidney disease (ESKD) and cardiovascular complications. Effective CKD management requires comprehensive care packages that integrate both pharmacological and non-pharmacological interventions within collaborative, team-based models, aiming to enhance patient outcomes and overall quality of life. The goal of the Strategies for Kidney Outcomes Prevention and Evaluation (SKOPE) study is to establish effective multicomponent intervention (MCI) strategies for evaluating and preventing kidney outcomes in patients with moderate to advanced CKD within primary care settings in Singapore. Methods This study is a 3-year randomized controlled trial among 896 participants aged between 40 and 80 years with moderate or advanced CKD in five government-subsidized polyclinics in Singapore. The components of the MCI are (1) nurses/service coordinators trained as health coaches for motivational conversation and CKD-specific lifestyle counseling on diet and exercise, using a hybrid follow-up approach of in-person, telephone, and secure video meetings; (2) training physicians in algorithm-based standardized management of CKD; (3) subsidy on SGLT2i medications for CKD; and (4) regular CKD case review meetings. The primary outcome is the estimated glomerular filtration rate (eGFR) total slope from randomization to final follow-up at 36 months. Discussion If shown to be effective, cost-effective, and acceptable, SKOPE should be considered for scaling country-wide and in similar regional healthcare systems. Trial registration ClinicalTrials.gov NCT05295368. Registered on March 25, 2022.

Abstract Background Long-term management of patients with hypothyroidism on thyroxine replacement requires thyroid function test (TFT) monitoring once every six–12 months as recommended by clinical practice guidelines. This study determined their thyroid function status during two-year follow-up visits in primary care, and the factors influencing their thyroid status, and assessed the optimal interval for TFTs. Methods A retrospective cohort study was conducted on adults with a clinical diagnosis code for hypothyroidism in their electronic health records taken from a group of polyclinics in Singapore between July 2017 and June 2020. The follow-up thyroid status was categorized as under-replacement (TSH ≥ 3.70mIU/L), over-replacement (TSH ≤ 0.65mIU/L) or euthyroid (TSH 0.65–3.70mIU/L). The patients’ demographic, clinical and TFT data were analyzed using appropriate statistical tests during the two-year follow-up. Stepwise logistic regression analysis identified the factors associated with suboptimal thyroid control. Kaplan–Meier analysis was used to compare their thyroid function status in association with the interval between TFT monitoring. Results Data from 5,749 eligible subjects (mean age 62.1 ± 13.29 years; 79% female; 79.7% Chinese) were analyzed. After a two-year follow-up, 61.9% (n = 3558) of all subjects were euthyroid, with 29.5% (n = 1694) being under-replaced and 8.6% (n = 497) over-replaced. However, thyroid status did not differ significantly with the various dose regimen (daily, segmented, or alternate days) (p = 0.193). Stepwise logistic regression showed that thyroxine under-replacement was significantly associated with the male gender (AOR = 1.25,95%CI = 1.03–1.51,p = 0.02) and obesity (AOR = 1.34,95%CI = 1.08–1.66,p = 0.008). Every unit (μg/kg body weight) increase in the mean daily thyroxine dose was associated with 2.72 times greater odds of over-replacement. When comparing thyroid function monitoring at intervals of 13-24 months, monitoring at shorter intervals (≤ 12 months) was less likely to detect thyroxine under-replacement (AOR = 0.57,95%CI = 0.44–0.74,p

Chest pain is a common presenting complaint among patients visiting primary care1 and is a frequent reason for referral to the outpatient cardiology clinic. The European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines advocate estimating pre-test probability (PTP) of obstructive coronary artery disease (CAD) in the evaluation of stable chest pain in order to guide the need for and type of downstream investigations.2,3 The PTP of obstructive CAD depends on the clinical characteristics of the patient and disease prevalence. Since the introduction of the Diamond-Forrester model in 1979,4 contemporary risk scores, such as the CAD consortium score5 (CCS) and the ESC 2019 PTP risk score,2 have been developed.

Abstract Background There is an unmet need for precise biomarkers for early non-invasive breast cancer detection. Here, we aimed to identify blood-based DNA methylation biomarkers that are associated with breast cancer. Methods DNA methylation profiling was performed for 524 Asian Chinese individuals, comprising 256 breast cancer patients and 268 age-matched healthy controls, using the Infinium MethylationEPIC array. Feature selection was applied to 649,688 CpG sites in the training set. Predictive models were built by training three machine learning models, with performance evaluated on an independent test set. Enrichment analysis to identify transcription factors binding to regions associated with the selected CpG sites and pathway analysis for genes located nearby were conducted. Results A methylation profile comprising 51 CpGs was identified that effectively distinguishes breast cancer patients from healthy controls achieving an AUC of 0.823 on an independent test set. Notably, it outperformed all four previously reported breast cancer-associated methylation profiles. Enrichment analysis revealed enrichment of genomic loci associated with the binding of immune modulating AP-1 transcription factors, while pathway analysis of nearby genes showed an overrepresentation of immune-related pathways. Conclusion This study has identified a breast cancer-associated methylation profile that is immune-related to potential for early cancer detection.

Abstract Background Despite the potential advantages of Internet-based diabetes self-management education, its adoption was not widespread among Singapore’s public primary care clinics (polyclinics). An interactive online tool was thus developed to help educate patients with Type 2 diabetes mellitus (T2DM), and was now ready for user testing before implementation. Aim To explore the perceived utility and usability of the educational tool in patients with suboptimally-controlled T2DM in a Singapore primary care setting. Methods In-depth interviews were used to gather qualitative data from multi-ethnic Asian adults who had suboptimally-controlled T2DM. A total of 17 IDIs were conducted between April 2022 to March 2023, audio-recorded, transcribed, and analyzed to identify emergent themes via thematic analysis. Results Regarding utility, users found the educational tool useful because it provided them with information that was comprehensive, accessible, reliable, and manageable. Regarding usability, the majority of users reported that the educational tool was easy to use, and suggested ways to improve navigational cues, visual clarity, readability and user engagement. Conclusion Participants generally found the educational tool useful and easy to use. A revised educational tool will be developed based on their feedback and implemented in clinical practice.

Abstract Background The Diabetic Retinopathy Extended Screening Study (DRESS) aims to develop and validate a new DR/diabetic macular edema (DME) risk stratification model in patients with Type 2 diabetes (DM) to identify low-risk groups who can be safely assigned to biennial or triennial screening intervals. We describe the study methodology, participants’ baseline characteristics, and preliminary DR progression rates at the first annual follow-up. Methods DRESS is a 3-year ongoing longitudinal study of patients with T2DM and no or mild non-proliferative DR (NPDR, non-referable) who underwent teleophthalmic screening under the Singapore integrated Diabetic Retinopathy Programme (SiDRP) at four SingHealth Polyclinics. Patients with referable DR/DME (> mild NPDR) or ungradable fundus images were excluded. Sociodemographic, lifestyle, medical and clinical information was obtained from medical records and interviewer-administered questionnaires at baseline. These data are extracted from medical records at 12, 24 and 36 months post-enrollment. Baseline descriptive characteristics stratified by DR severity at baseline and rates of progression to referable DR at 12-month follow-up were calculated. Results Of 5,840 eligible patients, 78.3% (n = 4,570, median [interquartile range [IQR] age 61.0 [55–67] years; 54.7% male; 68.0% Chinese) completed the baseline assessment. At baseline, 97.4% and 2.6% had none and mild NPDR (worse eye), respectively. Most participants had hypertension (79.2%) and dyslipidemia (92.8%); and almost half were obese (43.4%, BMI ≥ 27.5 kg/m2). Participants without DR (vs mild DR) reported shorter DM duration, and had lower haemoglobin A1c, triglycerides and urine albumin/creatinine ratio (all p

Objectives Frequent attenders (FAs) visit healthcare settings at higher rates compared with the general population and use disproportionate amounts of healthcare resources. Frequent attendance (FA) has also been associated with greater morbidity and adverse socioeconomic circumstances. Our study aimed to describe the sociodemographic profile, clinical presentation, and healthcare utilisation patterns of adolescent FAs at polyclinics in Singapore and to determine the factors associated with adolescent FA.Design Retrospective electronic database analysis.Setting A cluster of eight state-subsidised public primary care clinics (polyclinics).Participants Multiethnic Asian adolescents aged 10–19 years who attended the eight polyclinics in 2021. FAs were defined as the top 10% of clinic attendees in terms of annual visit frequency.Results In 2021, 34 645 adolescents attended the polyclinics for 75 902 visits. Visits were for acute (52.8%), chronic (26.2%) and preventive (27.7%) care. FAs attended ≥4 visits annually, accounting for 14.4% of adolescents and 42.5% of total attendances. Compared with non-FAs, FAs were older (OR 1.16, 95% CI 1.15 to 1.18, p

Introduction Effectiveness of Patient Education Materials (PEMs) on NSAIDs is subjected to whether the patient is able to read and comprehend the information provided. This study assessed the readability, understandability and actionability of English-language NSAID-related PEMs targeted at patients or caregivers in Singapore. Methods PEMs obtained from healthcare institutions in Singapore and from two frequently used internet search engines using search terms “NSAID” or “non-steroidal anti-inflammatory drug” were analysed by two reviewers using Flesch-Kincaid Grade Level (FKGL) and Simple Measure of Gobbledygook (SMOG) to assess the readability of the PEMs. Patient Education Materials Assessment Tool for printable materials (PEMAT-P) and United Kingdom Association for Accessible Formats (UKAAF) was used to assess the PEMs’ understandability, actionability and physical properties. Results All 74 PEMs that were reviewed, except one, were assessed to be beyond readability of the general population which was defined as grade 6 and below. Their mean FKGL and SMOG scores were 13.3 ± 2.8 and 14.4 ± 2.1 respectively. There were no significant differences in the FKGL ( p = .20) and SMOG scores ( p = .52) between local and non-local PEMs. The PEMs satisfied majority of UKAAF’s requirements. The PEMs’ understandability and actionability scores were 80.5 ± 8.0% and 52.5 ± 19.0% respectively. Conclusions Current NSAIDs-related PEMs are pegged too high at a level for a significant portion of population in Singapore to read and comprehend the information for them to take appropriate actions to ensure safe use of NSAIDs to manage their medical conditions. However, they are generally well-designed to facilitate reading of the materials.

ObjectivesEarly smoking initiation has been associated with a higher risk of developing long-term smoking habit. There is a growing global consensus that demands raising the minimum legal age (MLA) for smoking as an approach to address this problem. Singapore successfully raised the MLA from 18 to 21 years in 2021. This study aimed to evaluate the awareness and attitude of multi-ethnic Asian youth (aged 15–24) on raising MLA to 21 and passive smoking.MethodsA cross-sectional survey comprising of 23 items was circulated via a secure internet-based platform, FORMSG between September and November 2022. Data were analyzed for descriptive statistics. Categorical variables were compared for association with receptivity toward change in MLA using Chi-Squared test and multivariable logistic regression analysis using Rstudio. Post-hoc Bonferroni correction were further utilized for pairwise comparison.ResultsMajority (80.3%) of the 608 participants expressed their support for MLA 21 implementation. Participants’ age was a significant variable as those aged 15–17 years old (OR = 2.1, 95%CI = 1.01–4.32, p = 0.048) showed a higher likelihood of supporting MLA implementation compared to those aged 21 and above. In addition, majority (89.8%) of them were also aware of the harmful effects of passive smoking. When it came to discouraging smoking among youth, family influence (64%) and school education (55.6%) emerged as the top strategies.ConclusionMost of the youth express strong support for raising the MLA to 21, with over 80% in favor of such change, reflects a significant harmony among youth in favor of tobacco-free environment.

Abstract Renin-angiotensin system inhibitors (RASi), particularly angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), are commonly used in the treatment of hypertension and are recommended for kidney protection. Uncertainty remains about the effectiveness of RASi being used as first-line antihypertensive therapy on eGFR maintenance compared to its alternatives, especially for those with no or early-stage chronic kidney disease (CKD). We conducted a retrospective cohort study of 19,499 individuals (mean age 64.1, 43.5% males) from primary care in Singapore with 4.5 median follow-up years. The study cohort included newly diagnosed individuals with hypertension (whose eGFR was mainly in CKD stages G1-G2) and initiated on ACEIs, ARBs, beta-blockers (BBs), calcium channel blockers (CCBs) or diuretics (Ds) as first-line antihypertensive monotherapy. We compared the estimated glomerular filtration rate (eGFR) curve before/after the drug initiation over time of patients under different drug classes and analyzed the time to declining to a more advanced stage CKD. Inverse probability of treatment weighting (IPTW) was used to adjust for baseline confounding factors. Two key findings were observed. First, after initiating antihypertensive drugs, the eGFR almost maintained the same as the baseline in the first follow-up year, compared with dropping 3 mL/min/1.73 m2 per year before drug initiation. Second, ARBs were observed to be slightly inferior to ACEIs (HR = 1.14, 95% CI = (1.04, 1.23)) and other antihypertensive agents (HR = 1.10, 95% CI = (1.01, 1.20)) in delaying eGFR decline to a more advanced CKD stage in the study population. Our results showed that initiating antihypertensive agents can significantly maintain eGFR for those newly diagnosed patients with hypertension. However, RASi may not be superior to other antihypertensive agents in maintaining eGFR levels for non-CKD or early stages CKD patients.

Background: HbA1c test is the most-ordered laboratory test in public primary care clinics, accounting for 17% of laboratory services. In recent years, there has been growing adoption of self-service technology in taking clinical measurements. However, there are currently no on-site self-testing HbA1c facilities. This study assessed patients’ acceptability and ability to perform self-testing of HbA1c levels and the feasibility of implementation in primary care setting. Methods: A total of 30 eligible diabetic patients were recruited in Tampines Polyclinic. Participants were shown a demonstration video before self-testing with a Point-of-Care HbA1c analyzer and completed a questionnaire after self-testing. The usability of the system was assessed using System Usability Scale (SUS). Acceptance and ability were assessed using either a five or six point-Likert Scale for the 7-step procedure. Fisher’s exact test was used to test for association with SUS score. Results: The study population comprises mainly males (60.0%), Chinese (50.0%), had highest qualification of secondary education and beyond (80.0%), with a mean age of 61.4 ± 8.3 years. The mean SUS score was 66.5 ± 13.3 and the average time taken to complete the HbA1c self-testing was 11.8 ± 4.5 min. No significant association was observed between demographics and SUS score. Although 40.0% of participants experienced some difficulty in inserting the cartridge into the analyzer, all were able to understand and follow the video and were willing to perform self-testing in the future. Conclusion: There is high level of acceptance and ability among diabetic patients to adopt HbA1c self-testing. It is feasible for use in primary care.

Background The SingHypertension primary care clinic intervention, which consisted of clinician training in hypertension management, subsidized single‐pill combination medications, nurse‐delivered motivational conversations and telephone follow‐ups, improved blood pressure control and cardiovascular disease (CVD) risk scores relative to usual care among patients with uncontrolled hypertension in Singapore. This study quantified the incremental cost‐effectiveness, in terms of incremental cost per unit reduction disability‐adjusted life years, of SingHypertension relative to usual care for patients with hypertension from the health system perspective. Methods and Results We developed a Markov model to simulate CVD events and associated outcomes for a hypothetical cohort of patients over a 10‐year period. Costs were measured in US dollars, and effectiveness was measured in disability‐adjusted life years averted. We present base‐case results and conducted deterministic and probabilistic sensitivity analyses. Based on a willingness‐to‐pay threshold of US $55 500 per DALY averted, SingHypertension was cost‐effective for patients with hypertension (incremental cost‐effectiveness ratio: US $24 765 per disability‐adjusted life year averted) relative to usual care. This result held even if risk reduction was assumed to decline linearly to 0 over 10 years but not sooner than 7 years. Incremental cost‐effectiveness ratios were most sensitive to the magnitude of the reduction in CVD risk; at least a 0.13% to 0.16% point reduction in 10‐year CVD risk is required for cost‐effectiveness. Probabilistic sensitivity analysis indicates that SingHypertension has a 78% chance of being cost‐effective at the willingness‐to‐pay threshold. Conclusions SingHypertension represents good value for the money for reducing CVD incidence, morbidity, and mortality and should be considered for wide‐scale implementation in Singapore and possibly other countries. Registration Information REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02972619.

BackgroundOver the past few decades, the incidence of dengue fever has considerably increased. Effective vector control strategies and specific protection using dengue vaccine are thought to be the key elements to combat dengue. The dengue incidence among the Singapore youths (15–24 years) was second only to that of adults (25–44 years). This study evaluated the knowledge and attitude of Singapore youths on dengue and its preventive measures.MethodsA cross-sectional study using online-based questionnaire survey was conducted among Singapore youths from September to November 2022. Data were analyzed for descriptive statistics whereas Chi-squared test, linear regression analysis and Pearson correlation were used to determine the association between demographic factors and youth’s attitude on dengue prevention using Rstudio.ResultsA total of 624 respondents completed the survey out of 1822 surveys distributed nation-wide, with a response rate of 34.2% (mean age 17.4 years ± 1.84; 59.3% female; 89.9% Chinese). The mean dengue knowledge scores of participants were 14.1 ±2.8. Univariate analysis showed that teenagers (15–19 years) had significantly higher knowledge score than the young adults (20–24 years) (β=0.82,95%CI = 0.13–1.51, p = 0.021). Majority of them were aware of the Mozzie Wipeout campaign (90.2%) followed by the release of Wolbachia mosquitos (69.1%). Two-thirds of the youths who were aware of Wolbachia and Gravitrap considered that it was effective in reducing dengue infection rates. Participants suggested information about the current dengue infection rate (71.9%) as the most effective of the five proposed strategies to improve uptake of dengue preventive measures. In comparison to young adults, teenagers were more likely to uptake dengue preventive measures if widespread mosquito control practices were implemented (69.1% vs. 42.3%).ConclusionThe overall knowledge of the youths on dengue and its prevention was satisfactory. Future health promotion campaigns targeting the youths should focus on transforming the knowledge into practice.

This paper described the use of photovoice within design thinking to empathise with patients’ challenges and co-create ideas on asthma management in Singapore. A one-day workshop was organised and conducted in Singapore by SingHealth Polyclinics to discuss the challenges and enablers of good asthma care and ideate innovations to address the issues discussed. The workshop was conceptualised based on the Stanford’s d: school Design Thinking Process: 1. empathise, 2. define, 3. ideate, 4. prototype, and 5. test, focussing on the first three stages. Empathise stage was executed by having two patients share their challenges and enablers of good asthma care using photovoice. Define and ideate stage were accomplished through the multidisciplinary team discussion, with the patient going to every group to allow them to seek clarifications and opinions on ideas. The study findings were summarised based on the Empathise, Define and Ideate stages. Thirty-seven healthcare providers attended—9 doctors, 14 nurses, 4 pharmacists, 3 clinical service, 3 medical students and 4 research staff. Participants’ feedback was collected via an online feedback form to evaluate the effectiveness of an innovation workshop. More than 90% of participants strongly agreed or agreed that they could generate ideas to improving asthma care, the workshop helped drive innovation, and the use of photovoice helped them empathise with patients challenges. A design thinking framework can be used for innovation workshops. Photovoice is a useful method for understanding the problems faced by patients. A multidisciplinary team format with patient involvement was highly favoured.

Abstract Evidence on the influence of patient characteristics on HbA1c treatment response for add-on medications in patients with type 2 diabetes (T2D) is unclear. This study aims to investigate the predictors of HbA1c treatment response for three add-on medications (sulfonylureas (SU), dipeptidyl peptidase-4 (DPP-4) and sodium–glucose cotransporter-2 (SGLT-2) inhibitor) in metformin monotherapy treated patients with T2D. This retrospective cohort study was conducted using the electronic health record data from six primary care clinics in Singapore. A total of 9748 adult patients with T2D on metformin monotherapy receiving SU, DPP-4 or SGLT-2 add-on were 1:1 propensity score matched to patients receiving other add-on medications. Patient demographics, laboratory results, diabetes related complications, comedications, and treatment response at two endpoints (HbA1c reduction ≥ 1% at 6th month, HbA1c goal attainment

Abstract Background Type 2 diabetes (T2D), a major risk factor for cardiovascular disease and other adverse health conditions, is on the rise in Singapore. TRIPOD is a randomized controlled trial aimed to determine whether complementing usual care with an evidence-based diabetes management package (DMP) —comprising access to an evidence-based app, health coaching, pedometer, glucometer and weighing scale, with or without a financial rewards scheme (M-POWER rewards), can improve mean HbA1c levels at months 6 and 12. Methods The protocol was published in Trials, accessible via https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-019-3749-x 1. This manuscript updates the protocol with changes to the study design due to challenges with recruitment and presents baseline characteristics. Key updates include changing the arm allocation ratio from 1:1:1 (Arm 1-Usual Care: Arm 2-DMP: Arm 3-DMP+M-POWER rewards) to 10:1:10, the sample size from 339 to 269, the intervention period from two to one year, and the primary hypothesis to focus solely on differences between Usual Care and DMP+M-POWER rewards. Recruitment for the study began on 19 October 2019 and ended on 4 June 2022. Results The average age of participants was 55.0 (SD9.7) years old and 64.2% were male. The majority of participants (76.8%) were Chinese, 4.9% Malay and 18.3% Indian and of other ethnicities. 67.0% had a monthly household income of SGD$4000 or more. The mean baseline HbA1c was 8.10% (SD 0.95) and the mean body mass index was 26.8 kg/m2 (SD 5.3). Discussion The final participant completed month 12 follow-up data collection on 8 June 2023. All pre-planned analyses will be conducted and final results reported. Trial registration ClinicalTrials.gov NCT03800680 . Registered on 11 January 2019.

Abstract Background Blood-based DNA methylation has shown great promise as a biomarker in a wide variety of diseases. Studies of DNA methylation in blood often utilize samples which have been cryopreserved for years or even decades. Therefore, changes in DNA methylation associated with long-term cryopreservation can introduce biases or otherwise mislead methylation analyses of cryopreserved DNA. However, previous studies have presented conflicting results with studies reporting hypomethylation, no effect, or even hypermethylation of DNA following long-term cryopreservation. These studies may have been limited by insufficient sample sizes, or by their profiling of methylation only on an aggregate global scale, or profiling of only a few CpGs. Results We analyzed two large prospective cohorts: a discovery (n = 126) and a validation (n = 136) cohort, where DNA was cryopreserved for up to four years. In both cohorts there was no detectable change in mean global methylation across increasing storage durations as DNA. However, when analysis was performed on the level of individual CpG methylation both cohorts exhibited a greater number of hypomethylated than hypermethylated CpGs at q-value

BackgroundCare continuity by a dedicated, well-trained primary care physician (PCP) has shown to improve health outcomes of patients with non-communicable diseases (NCDs). In Singapore's fee-for-service primary care system, patients can choose to consult any PCP in either a public (polyclinic), private (General Practitioners/ GP), or both types of clinics, resulting in potential fragmented care. Decision-making by patients in selecting their preferred PCP remains unclear. This study aims to explore the personal factors influencing the choice of PCP among patients with NCDs in primary care.MethodsThis qualitative research study was conducted in a typical polyclinic. In-depth interviews were conducted on patients with NCDs. Purposive sampling was implemented to enrol patients who had previously consulted PCPs in polyclinics and GP clinics, garnering their perspectives and experiences of care received from both providers. Interviews were audio-recorded, transcribed, and audited. Data was coded and analysed using thematic content analysis to identify emerging themes. The physician-specific factors which influence patients' decision-making of PCP selection are presented here.ResultsTwenty-one Asian patients aged 38 to 82 years were interviewed. They preferred PCPs with an approachable and genuine demeanour, exhibiting empathy and compassion. They valued the PCPs' verbal, non-verbal and listening skills. Regarding professional qualities, patients wanted PCPs to demonstrate competency and a patient-centred care approach. Some selected their PCP based on compatible age and gender that they felt comfortable with. Establishing good rapport with their PCP and maintaining continuity of care were deemed as major factors in patients' PCP selection.ConclusionPatients tended to select PCPs based on their personal characteristics, interpersonal skills, professional attributes, demographics, and the physician-patient relationship. PCPs should be aware of these attributes and demonstrate them during their patient interaction. Leveraging on this enables PCPs to build rapport with their patients and maintain care continuity to optimize their health outcomes.

IntroductionDiabetes and hypertension are prevalent and costly to the health system. We have developed a mobile app (EMPOWER app) which enables remote monitoring and education through personalised nudges. We aim to study the effectiveness of a multi-component intervention comprising the EMPOWER mobile app with health coaching and shared decision-making for diabetes and hypertension.MethodsWe will conduct a two-arm, open-label, pragmatic randomised controlled trial (RCT). Participants with comorbid diabetes and hypertension enrolled from public primary care clinics will be randomised to either intervention or control in a 1:1 ratio. The intervention group participants will have access to health coaching with shared decision-making interventions in addition to the EMPOWER app and their usual primary care. The control group participants will continue to receive usual primary care and will neither receive the EMPOWER app nor health coaching and shared decision-making interventions. Our primary outcome is change in HbA1c level over 9 months. Secondary outcomes include change in systolic blood pressure, quality of life, patient activation, medication adherence, physical activity level, diet, and healthcare cost (direct and indirect) over 9 months.DiscussionOur trial will provide key insights into clinical- and cost-effectiveness of a multi-component intervention comprising EMPOWER mobile app, health coaching and shared decision-making in diabetes and hypertension management. This trial will also offer evidence on cost-effective and sustainable methods for promoting behavioural changes among patients with comorbid diabetes and hypertension.Trial registrationThis study was registered on clintrials.gov on August 3, 2022, with the trial registration number: NCT05486390.

Introduction: Self-efficacy in individuals optimizes their hypertension management. Electronic patient portals are being increasingly used to support chronic disease management, as they raise the health literacy of patients and enable them in self-management. However, the association between the use of patient portals and self-efficacy in hypertension management remains unclear. The study aimed to determine the association between self-efficacy among patients with hypertension who are managed in primary care and their demographic characteristics and usage patterns of patient portals. Method: A cross-sectional survey was conducted at a public primary care clinic in urban Singapore. Multi-ethnic adult patients with hypertension were invited to participate in a self-administered electronic questionnaire. Chi-square test was performed for bivariate analysis; adjusted logistic regression models were used for factors with P value $5000 (AOR = 2.324, 95%CI = 1.104-4.892; P = .026), and post-secondary education level (AOR = 3.128, 95%CI = 1.675-5.839; P

Background: The COVID-19 pandemic increased the use of telemedicine in primary care services. Understanding patients’ perspectives on telemedicine is pivotal for its wider adoption in managing non-communicable diseases (NCDs) in the community. Aim: To explore the views and concerns of patients who have yet to use video consultation (VC) for NCD management in Singapore. Design & setting: This qualitative study was conducted in a primary care clinic in Singapore. Method: In total, 16 patients participated in individual in-depth interviews. The participants had type 2 diabetes mellitus and/or hypertension and/or hyperlipidaemia without prior VC experience. They were purposively enrolled in the polyclinic. Audited transcripts were independently coded by two investigators. Thematic analysis was performed to identify perspectives on telemedicine based on the health, information, and technology zones of the Health Information Technology Acceptance Model. Results: The following three themes emerged: perceived benefits of VC utility; perceived barriers of VC adoption; and potential challenges of VC. Participants viewed VC as safe and convenient if they had stable NCD. They voiced concerns on possible suboptimal care owing to the absence of physical examination, network connectivity, and personal medical data security. Participants highlighted challenges of VC uptake such as digital health familiarity, availability of their own mobile and telemonitoring devices, and healthcare costs consideration. Conclusion: Addressing the concerns and challenges highlighted by non-VC users can help physicians and policymakers explore ways to scale up telemedicine in Singapore. A hybrid clinical care model comprising in-person visits and VC may be the way forward for NCD management.

Abstract BackgroundNeonatal jaundice (NNJ) or hyperbilirubinemia is a ubiquitous condition in newborn infants. Currently, the transcutaneous bilirubinometer is used to screen for NNJ in health care facilities, where neonates need to be physically present (ie, a centralized model of care for NNJ screening). Mobile health (mHealth) apps present a low-cost, home-based, and noninvasive system that could facilitate self-monitoring of NNJ and could allow mothers the convenience of screening for NNJ remotely. However, end users’ acceptability of such mHealth apps is of fundamental importance before the incorporation of such apps into clinical practice. ObjectiveThe study aimed to explore the perception of postpartum mothers toward self-monitoring of NNJ using a novel mHealth app. MethodsMothers attending video consultations for early postpartum care at 2 Singapore primary care clinics watched an instructional video for a hyperbilirubinemia-screening mHealth app (HSMA). An independent researcher used a semistructured topic guide to conduct in-depth interviews with 25 mothers, assessing their views on HSMAs. All interviews were audio recorded, transcribed verbatim, and checked for accuracy before data analysis. Two researchers independently analyzed the transcripts via thematic analysis. Data were managed using NVivo qualitative data management software. ResultsThe identified themes were grouped under perceived usability and utility. Mothers valued the convenience and utility of HSMAs for remote monitoring of NNJ. They appreciated the objectivity the app readings provided compared to visual inspection. However, they perceived that the app’s applicability would be restricted to severe jaundice, were concerned about its accuracy and restriction to the English language, and lacked confidence in using it. Nevertheless, they were willing to use it once its accuracy was proven and when they received adequate guidance from health care professionals. They also suggested including an action plan for the measured readings and clinical signs within the app. Mothers proposed pairing teleconsultations with HSMAs to boost their confidence and enhance adoption. ConclusionsMothers were receptive to using HSMAs but had concerns. Multiple languages, proof of accuracy, and resources to guide users should be incorporated into the app in the next phase to increase its successful adoption. Complementing such apps with a teleconsultation service presents a plausible and pragmatic NNJ care delivery model in general practice.

Objective: In an earlier study, several tested International Pharmaceutical Federation (FIP) pictograms did not achieve validity among older adults in Singapore. In this study, for 27 unvalidated FIP pictograms, we (1) developed variants of each pictogram, (2) elicited the most-preferred variant, and (3) assessed the validity of the most-preferred variant among older Singaporeans. Methods: In phase 1, up to three variants of the 27 pictograms were developed, based on older adults' feedback from a previous study. In phase 2, the most-preferred variant of 26 pictograms, which had two or three variants, was selected by 100 older participants. In phase 3, the 27 most-preferred variants (including the pictogram with only one variant) were assessed for validity – transparency and translucency – among 278 older participants (10 pictograms per participant). To evaluate transparency, participants were first asked: “If you see this picture on a medicine label, what do you think it means?” for each assigned pictogram. If they responded, they were asked, “How do you know?”, and if not, they were told, “Tell me everything you see in this picture”. Then, participants were shown their assigned pictograms again, one by one, and the pictogram's intended meaning was revealed to evaluate translucency. Pictograms were classified as valid (≥66% participants interpreted its intended meaning correctly [transparency criterion] and ≥85% participants rated its representativeness as ≥ 5 [translucency criterion]), partially valid (only transparency criterion fulfilled) or not valid. Results: In phase 1, 77 variants of the 27 pictograms were developed. In phase 2, a majority of the most-preferred variants were selected by >50% participants. In phase 3, 10 (37.0%) of the 27 pictograms tested were considered valid, and five (18.5%) were partially valid. A higher proportion of pictograms portraying dose and route of administration and precautions were valid or partially valid, versus those depicting indications or side effects. Conclusion: Contextual redesigning and selection of pharmaceutical pictograms, which initially failed to achieve validity in a population, contributed to their validation. Innovation: The redesigned validated pictograms from this study can be incorporated into relevant patient information materials in clinical practice.

Abstract Background Distinguishing whether and how pre-existing characteristics impact maternal responses to adversity is difficult: Does prior well-being decrease the likelihood of encountering stressful experiences? Does it protect against adversity’s negative effects? We examine whether the interaction between relatively uniformly experienced adversity (due to COVID-19 experience) and individual variation in pre-existing (i.e., pre-pandemic onset) distress predicted mothers’ pandemic levels of distress and insensitive caregiving within a country reporting low COVID-19 death rates, and strict nationwide regulations. Method Fifty-one Singaporean mothers and their preschool-aged children provided data across two waves. Pre- pandemic onset maternal distress (i.e., psychological distress, anxiety, and parenting stress) was captured via self-reports and maternal sensitivity was coded from videos. Measures were repeated after the pandemic’s onset along with questionnaires concerning perceived COVID-19 adversity (e.g., COVID-19’s impact upon stress caring for children, housework, job demands, etc.) and pandemic-related objective experiences (e.g., income, COVID-19 diagnoses, etc.). Regression analyses (SPSS v28) considered pre-pandemic onset maternal distress, COVID-19 stress, and their interaction upon post-pandemic onset maternal distress. Models were re-run with appropriate covariates (e.g., objective experience) when significant findings were observed. To rule out alternative models, follow up analyses (PROCESS Model) considered whether COVID-19 stress mediated pre- and post-pandemic onset associations. Models involving maternal sensitivity followed a similar data analytic plan. Results Pre-pandemic maternal distress moderated the association between COVID-19 perceived stress and pandemic levels of maternal distress (β = 0.22, p

Abstract The study aimed to determine the resilience of multi-ethnic, multi-cultural adolescent students in cosmopolitan Singapore, their coping abilities, and the impact on their social and physical activities during the COVID-19 pandemic and its association with their resilience. A total of 582 adolescents in post-secondary education institutes completed an online survey from June to November 2021. The survey assessed their sociodemographic status, resilience level using the Brief Resilience Scale (BRS) and Hardy-Gill Resilience Scale (HGRS), the impact of the COVID-19 pandemic on their daily activities, life settings, social life, social interactions, and coping ability in these aspects of life. Poor ability to cope with school life (adjusted beta = − 0.163, 95% CI − 1.928 to 0.639, p

Herpes zoster (HZ) causes significant morbidity, particularly in older adults. With the advent of a recombinant zoster vaccine, HZ is potentially preventable. However, data on HZ burden and healthcare utilization in primary care populations remains scarce. This study described the prevalence and healthcare utilization in managing HZ in a developed community. A retrospective database review was conducted across a cluster of 8 public primary care clinics in urban Singapore. Data of multi-ethnic Asian patients with a diagnosis code of “herpes zoster” from 2018 to 2020 was extracted from their electronic medical records. Socio-demographic, clinical, visitation, medical leave, prescription, and referral data were analyzed. A total of 2,987 out of 737,868 individuals were diagnosed with HZ over 3 years. The mean age was 59.9 (SD + 15.5) years; 49.2% were male; 78.5% Chinese, 12.2% Malay, and 4.1% Indian. The prevalence was 221, 224, 203 per 100,000 persons in 2018, 2019, and 2020, respectively. The 70 to 79-year age group had the highest prevalence (829/100,000) across 3 years. Oral acyclovir (median daily dose 4,000 mg; median duration 7 days) and topical acyclovir were prescribed in 71.6 and 47.6%, respectively. Analgesia prescribed were gabapentin (41.0%), paracetamol combinations (30.1%), oral NSAIDs (23.7%), opioids (6.0%), and tricyclic antidepressants (1.9%). Most individuals consulted only once (84.3%); 32.7% of them required medical leave and 5.6% had more than 7 days of absenteeism. HZ-related referrals to the hospital were required in 8.9% (4.9% emergency, 2.8% ophthalmology). The findings of this study suggest a need for HZ vaccination among older age groups. Visitation and referral rates were low. The use of topical acyclovir was uncovered, and further research should evaluate the underlying reasons, benefits, and harms of such practice. The use of analgesia combinations may be explored further.

BackgroundGout is associated with significant morbidity and mortality, yet suboptimal gout control remains a problem globally. Identifying the risk factors associated with poor gout control among patients in primary care allows targeted interventions to improve their clinical management. This study aimed to determine the prevalence of poor gout control and its associated demographic and clinical factors among urbanized community-dwelling Asian patients.MethodsThis retrospective study was based on data extracted from the electronic medical records of 8 public primary care clinics in Singapore. Patients with a diagnostic code of gout who had 2 or more visits between 1st January 2018 and 31st December 2019 were included in the analysis. Data extracted included: demographics, anthropological measurements, comorbidities, serum uric acid levels and medication prescription. A patient is defined to have poor gout control if they suffer two or more acute gout attacks within a year. Chi-Squared test was used for categorical parameters. For continuous variables, univariate logistic regression analysis was first performed. Significant factors (p ≤ 0.1) were then included in the logistics regression model to account for confounders.ResultsA total of 7,970 patients and 24,624 visits were included in the analysis. The prevalence of poorly controlled gout was 28.2% (n = 2,244/7,970); only 46.3% of them (n = 1,039/2,244) were prescribed allopurinol and 13.4% (n = 301/2,244) were taking doses ≥300 mg. Using logistic regression, factors associated with poor gout control were: male gender [adjusted OR (AOR) =1.66, p

Abstract Background Diabetes-related distress (DRD) is a negative emotional state related to the burden of living with diabetes mellitus. It has been associated with poor self-care and glycaemic control. This cross-sectional study aimed to examine the factors associated with DRD among urban Asian patients with poorly controlled type-2 diabetes mellitus (T2DM) in primary care in Singapore. The factors included demographics, diabetes history, medical co-morbidities, mood disorders and social history. Methods Patients with T2DM and HbA1c of 8% or more were recruited from 2 public primary care centres in Singapore. They were administered a questionnaire survey to identify DRD based on the Problem Area In Diabetes (PAID) scale. Their anxiety and depression were screened using GAD-7 and PHQ-9, and quality of life (QOL) measured using the EQ-5D-5L. Their clinical data, including HbA1c, comorbidities and medications, were extracted from the electronic medical records. Results Among the 356 subjects, the prevalence of DRD was 17.4%. DRD was significantly associated with younger age (AOR (95% CI) = 0.93 (0.89–0.97), p = 0.001), ex-smoker status (AOR (95% CI) = 22.30 (2.43–204.71), p = 0.006) and history of kidney disease (AOR (95% CI) = 3.41 (1.39–8.35), p = 0.007). Those who screened positive for depression (AOR (95% CI) = 4.98 (1.19–20.86), p = 0.028) were almost five times more likely to have DRD. Quality of life was lower among those with DRD (EQ5D index score AOR (95% CI) = 0.11 (0.01–0.97), p = 0.047), who also tended to feel that diabetes pharmacotherapy interfered with their normal life (AOR (95% CI) = 2.89 (1.38–6.08), p = 0.005). Conclusion About 1 in 6 patients with poorly controlled T2DM had DRD. Younger age, ex-smoker status, history of kidney disease, and those with depressive symptoms were most at risk.

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.

Abstract Background There is an increasingly strong association between sarcopenia and malnutrition in research findings. We aimed to determine the prevalence and factors associated with sarcopenia in community-dwelling older adults (≥ 65 years) at risk of malnutrition based on Malnutrition Universal Screening Tool (MUST). Methods This was a cross-sectional study of 811 participants. Participants were recruited from the general population, community centers, senior activity centers, polyclinics, and hospital. Community-dwelling older adults at risk of malnutrition participated in the study. Participants’ data and measurements were collected at the baseline visit. Data included socio-demographic information, anthropometric measurements, body composition, dietary intakes, and functional assessments. Sarcopenia was defined using the Asian Working Group for Sarcopenia 2019 consensus. Results Of the 694 participants with complete datasets, overall prevalence of sarcopenia was 76% (n = 530); 57% (n = 393) had severe sarcopenia. In the overall cohort, compared to participants without sarcopenia, those with sarcopenia were older, had lower physical activity scale for the elderly score, leg strength, handgrip endurance, mid-upper arm circumference, calf circumference, and bone mass, and had lower dietary protein intake and poorer nutritional status (all p ≤ 0.015). After adjusting for confounders, sarcopenia was significantly associated with older age, male gender, higher risk of malnutrition, lower calf circumference, and lower bone mass (all p ≤ 0.044). Conclusions In community-dwelling older adults at risk of malnutrition, there is a high prevalence of sarcopenia and severe sarcopenia. As such, screening positive for either malnutrition risk or sarcopenia in older adults should prompt screening for the other risk factor, to allow early institution of disease modifying interventions to forestall adverse outcomes for both malnutrition and sarcopenia. Trial registration The study was registered at clinicaltrials.gov as NCT03245047 .

Abstract Type-2 diabetes mellitus (T2DM) is a medical condition in which oral medications avail to patients to curb their hyperglycaemia after failed dietary therapy. However, individual responses to the prescribed pharmacotherapy may differ due to their clinical profiles, comorbidities, lifestyles and medical adherence. One approach is to identify similar patients within the same community to predict their likely response to the prescribed diabetes medications. This study aims to present an evidence-based diabetes medication recommendation system (DMRS) underpinned by patient similarity analytics. The DMRS was developed using 10-year electronic health records of 54,933 adult patients with T2DM from six primary care clinics in Singapore. Multiple clinical variables including patient demographics, comorbidities, laboratory test results, existing medications, and trajectory patterns of haemoglobin A1c (HbA1c) were used to identify similar patients. The DMRS was evaluated on four groups of patients with comorbidities such as hyperlipidaemia (HLD) and hypertension (HTN). Recommendations were assessed using hit ratio which represents the percentage of patients with at least one recommended sets of medication matches exactly the diabetes prescriptions in both the type and dosage. Recall, precision, and mean reciprocal ranking of the recommendation against the diabetes prescriptions in the EHR records were also computed. Evaluation against the EHR prescriptions revealed that the DMRS recommendations can achieve hit ratio of 81% for diabetes patients with no comorbidity, 84% for those with HLD, 78% for those with HTN, and 75% for those with both HLD and HTN. By considering patients’ clinical profiles and their trajectory patterns of HbA1c, the DMRS can provide an individualized recommendation that resembles the actual prescribed medication and dosage. Such a system is useful as a shared decision-making tool to assist clinicians in selecting the appropriate medications for patients with T2DM.

Abstract Background Making high-quality decisions when selecting treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) requires a shared decision-making approach. However, older people with lower health literacy face barriers. The pilot study aimed to evaluate the feasibility of recruiting participants and evaluate the effectiveness of a multi-level intervention on decision quality for the treatment of LUTS/BPH. Method In this 2-arm, randomized controlled trial, multi-ethnic Asian men aged ≥ 50 years with moderate or severe symptoms (IPSS ≥ 8 and/or QOL ≥ 3) and physicians were recruited at a Singapore public primary care clinic. Men were randomized to either physicians trained in shared decision-making and used a pictorial patient-reported symptom score (Visual Analogue Uroflowmetry Score) during the consultation or to physicians untrained in shared decision-making who did not use the score. Decision quality was measured using SDMQ-9 scores from men and their physicians after the consultation. Results 60 men (intervention [n = 30], control [n = 30]) receiving care from 22 physicians were recruited. Men’s mean age was 70 ± 9 years: 87% were Chinese, 40% had no formal education, and 32% were of lower socioeconomic status. No difference in decision quality from the men’s nor their physicians’ perspectives was noted [for men: mean score = 70.8 (SD 20.3) vs. 59.5 (SD 22.4); adjusted p = 0.352] [for physicians: mean score = 78.1 (SD 14.1) vs. 73.2 (SD 19.8); adjusted p > 0.999]. Conclusion It was feasible to recruit the intended participants. There was no difference in decision quality between men who used shared decision-making and usual care for the treatment of LUTS/BPH.

Background Potentially inappropriate prescribing (PIP) is common in primary care and is associated with adverse outcomes. Knowledge of the risk factors of PIP can be critical in designing PIP interventions, especially in guiding our understanding on how PIP occurs in primary care. Objective This systematic review examined factors associated with PIP, specific to primary care. Methods We searched PubMed, Embase, CINAHL, Web of Science, Scopus and PsycINFO for studies related to ‘older persons’, ‘primary care’ and ‘inappropriate prescribing’. Two reviewers conducted study selection, data extraction and quality appraisal. Factors associated with PIP were narratively synthesized. Results Of the 1017 articles identified, we included 25 articles and a total of 2,893,925 participants, with average age of 70.4–84.0 years. Risk factors of PIP could be classified into patient, physician and system factors. Patient factors were related to patient demographics (advanced age, lower education level and lower socioeconomic status), medical comorbidities (polypharmacy and multimorbidity) and lifestyle factors (unhealthy habits and use of over-the-counter medications). Physician and system factors included older, male, solo general practitioner (GP), higher number of visits of pharmaceutical sales representatives to GP, centrally located GP practice, and smaller number of older patients following up with GP, and medication source from public health system. Conclusions The findings provide contextual information to guide our understanding of PIP in primary care. Factors identified in this review can inform the design of complex interventions for PIP, as well as be used to develop risk prediction tools to identify high-risk groups who may require further interventions related to PIP.

Abstract Background The postpartum period is a critical time for women to optimise their physical and mental health. Primary care physicians (PCP) often manage postpartum women in the community setting after uneventful births. However, women encounter difficulties accessing care before and after their conventional 6-week physical review. Telehealth-based interventional studies have demonstrated their successful applications in several areas of postpartum care but is not widely adopted. The study aimed to explore the PCPs’ views on their acceptability and perceived barriers of telehealth in delivering postpartum care to women in primary care. Methods Twenty-nine PCPs participated in eleven in-depth interviews and four focus group discussions for this qualitative study conducted in Singapore. The purposively sampled PCPs had varied demographic background and medical training. Two investigators independently coded the audited transcripts. Thematic content analysis was performed using the codes to identify issues in the pertaining to the perceived usefulness, ease of use and attitudes towards telehealth in postpartum care as described in the “Telehealth Acceptance Model” framework. Results Most PCPs perceived usefulness and ease of use of video consultation in delivering postpartum care. They recognised telehealth service to complement and support the current face-to-face postpartum care amidst the pandemic. However, training, leadership support, organizational infrastructure, healthcare financial policy and personal demographic profile influence their acceptance of a new care model for postnatal mothers. Conclusion Addressing the barriers and strengthening the facilitators will enhance PCPs’ acceptance and utilisation of the proposed hybrid (telehealth and in-person) postnatal care model for mothers.

BackgroundAcne vulgaris (acne) is common among young persons (YPs). Clinical practice guidelines are available for acne management to minimize their physical and psychological impact. However, evidence of adherence to these guidelines is sparse in primary care practices. The study aimed to determine the demographic profile of YPs who sought primary care consultations for acne, their related prescriptions and referrals to specialists for further management.MethodA retrospective study was conducted using data from a cluster of eight public primary care clinics in Singapore. Demographic, clinical, prescription, and referral data were extracted from the electronic health records of YPs aged 10–29 years with a documented diagnosis of acne (ICD-10 classification) from 1st July 2018 to 30th June 2020. The data were reviewed, audited for eligibility criteria, and de-identified before analysis.ResultsComplete data from 2,700 YPs with acne were analyzed. Male (56.1%) YPs and those of Chinese ethnicity (73.8%) had the most frequent attendances for acne. The mean and median age at presentation was 19.2 (standard deviation = 4.3) and 19 (interquartile range = 16–22) years, respectively. Only 69.7% of YPs received an acne-related medication; 33.5% received antibiotic monotherapy; 53.0% were prescribed oral doxycycline, 35.0% acne cream (combination of sulfur, salicylic acid, and resorcinol), and 28.4% benzoyl peroxide 5% gel; 54.3% of those treated with antibiotics were prescribed with a shorter duration than recommended; 51.3% were referred to a dermatologist on their first visit, and 15.8% had more than one visit.ConclusionAcne management for YPs can be enhanced with refresher training among primary care physicians for better adherence to its clinical practice guidelines.

Background: Prescription medication labels (PMLs) predominantly dispensed in English, are an important adjunct to medication counselling. PMLs are routinely used by pharmacy staff to counsel older adults about their medications. This study sought to identify challenges that pharmacy staff observe older adults face in using their PMLs, and to identify and quantify solutions employed by pharmacy staff during medication counselling to address such challenges. Methods: Ten in-depth interviews were done with primary care pharmacy staff to gather the range of challenges and solutions. Subsequently, a quantitative survey, informed by the qualitative findings, was administered to 121 pharmacy staff to assess if the reported solutions were commonly used. Results: The two main challenges were incongruity between PML language (English) and older adults' language proficiency, and poor PML legibility. The solutions, classified under three themes, were simplifying medication information on PMLs, supplementing PMLs with additional medication information and mitigating poor readability. Conclusions: Pharmacy staff observed challenges faced by older adults in using PMLs during medication counselling. Ad-hoc improvisations by pharmacy staff to PMLs were pervasive. System-level PML improvements, such as provision of legible bilingual medication instructions, pharmaceutical pictograms and additional medication information, through patient information leaflets or using quick response (QR) codes on PMLs, should be considered. This will facilitate patient-provider communication, especially in settings with language dissonance between PMLs and patients.

Abstract Background Muscle health decline with age, but its deterioration in older persons with type-2 diabetes mellitus (T2DM) over time is not well-established. This study aimed to determine the change in muscle mass, handgrip strength and gait speed over time among community-dwelling ambulatory older multi-ethnic Asian patients with T2DM and their associated factors. Methods Among 387 eligible patients aged 60–89 years who were recruited at baseline, 348 (89.9%) were reviewed at a public primary care clinic in Singapore in the subsequent 9 to 34 months. The change in their clinical and functional status, levels of physical activity and muscle status (mass, grip strength and gait speed based on the Asian Working Group for Sarcopenia criteria) were recorded and compared. Their physical activity levels were assessed using the Physical Activity Scale for the Elderly (PASE) and International Physical Activity Questionnaire (IPAQ). Their quality of life was evaluated based on the World Health Organization Quality of Life (WHOQOL) domains. Linear regression analysis was used to identify the factors associated with muscle health change. Results The study population comprised men (52.9%), Chinese (69.3%), mean age of 68.4 ± SD5.6 years and had at least secondary education (76.4%). Their mean muscle mass significantly decreased by 0.03 ± SD0.06 kg/m2/month, mean handgrip strength by 0.06 ± SD0.26 kg/month and negligible change in gait speed of 0.002 ± SD0.01 m/sec/month. Their mean weight significantly decreased by 0.5 ± SD3.9 kg, waist and hip circumferences by 2.5 ± SD6cm and 3.2 ± SD5.1 cm respectively, with no change in BMI. Linear regression shows significant associations between muscle mass change and education level (β = 0.36,p = 0.012, 95% CI = 0.08–0.64), BMI (β = 0.11,p =

Abstract 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.

Abstract Background Clinical trials have demonstrated that initiating oral anti-diabetic drugs (OADs) significantly reduce glycated hemoglobin (HbA1c) levels. However, variability in lifestyle modifications and OAD adherence impact on their actual effect on glycemic control. Furthermore, evidence on dose adjustments and discontinuation of OAD on HbA1c is lacking. This study aims to use real-world data to determine the effect of OAD initiation, up-titration, down-titration, and discontinuation on HbA1c levels, among Asian patients managed in primary care. Methods A retrospective cohort study over a 5-year period, from Jan 2015 to Dec 2019 was conducted on a cohort of multi-ethnic adult Asian patients with clinical diagnosis of type 2 diabetes mellitus (T2DM) managed by a network of primary care clinics in Singapore. Nine OADs from five different classes (biguanides, sulphonyurea, dipeptidyl peptidase-4 [DPP-4] inhibitors, sodium-glucose cotransporter-2 [SGLT-2] inhibitors, and alpha-glucosidase inhibitors) were evaluated. Patients were grouped into “No OAD”, “Non-titrators,” and “Titrators” cohorts based on prescribing patterns. For the “Titrators” cohort, the various OAD titrations were identified. Subsequently, a descriptive analysis of HbA1c values before and after each titration was performed to compute a mean difference for each unique titration identified. Results Among the cohort of 57,910 patients, 43,338 of them had at least one OAD titration, with a total of 76,990 pairs of HbA1c values associated with an OAD titration. There were a total of 206 unique OAD titrations. Overall, initiation of OADs resulted in a reduction of HbA1c by 3 to 12 mmol/mol (0.3 to 1.1%), respectively. These results were slightly lower than those reported in clinical trials of 6 to 14 mmol/mol (0.5 to 1.25%). The change of HbA1c levels due to up-titration, down-titration, and discontinuation were −1 to −8 mmol/mol (−0.1 to −0.7%), +1 to 7 mmol/mol (+0.1 to +0.6%), and +2 to 11 mmol/mol (+0.2 to +1.0%), respectively. The HbA1c lowering effect of initiating newer OADs, namely DPP-4 inhibitors and SGLT-2 inhibitors was 8 to 11 mmol/mol (0.7 to 0.9%) and 7 to 11 mmol/mol (0.6 to 1.0%), respectively. Conclusion The real-world data on Asians with T2DM in this study show that the magnitudes of OAD initiation and dose titration are marginally lower than the results from clinical trials. During shared decision-making in selecting treatment options, the results enable physicians to communicate realistic expectation of the effect of oral medications on the glycemic control of their patients in primary care.

ObjectivesThis systematic review aimed to evaluate the association between smartphone addiction and sleep in medical students. The secondary outcomes included the prevalence of smartphone addiction, duration and purpose of its use, prevalence of poor sleep, duration and quality of sleep.MethodsThe authors searched PubMed, Cochrane Library, Embase, PsycINFO and CINAHL databases, from inception of each database to October 2022. Quantitative studies in the English language on smartphone addiction and sleep in students studying Western Medicine were included. The Rayyan application was used for title-abstract screening, and Joanna Briggs Institute (JBI) critical appraisal checklist to assess the risk of bias. Heterogeneity tests and meta-synthesis of data were performed using the meta-package in R software. Data on the activities used on the smartphone was synthesized qualitatively.ResultsA total of 298 abstracts were initially assessed for inclusion eligibility: 16 of them were eventually appraised, covering 9466 medical students comprising 3781 (39.9%) males and 5161 (54.5%) females. Meta-correlation between the Smartphone Addiction Scale Short Version (SAS-SV) and Pittsburgh Sleep Quality Index (PSQI) was 0.30 (95%CI = 0.24-0.36), and 0.27 (95% CI = 0.18-0.36) for SAS-SV and sleep duration. The meta-analytic estimation of smartphone addiction prevalence was 39% (95%CI = 0.30-0.50), and score using SAS-SV was 31.11 (95%CI = 29.50-32.72). The mean duration of smartphone daily used was 4.90 hours (95%CI = 3.72-6.08). The meta-analytic estimation on prevalence of poor sleep was 57% (95%CI = 0.48-0.66), and the meta-mean of PSQI and duration of sleep was 5.95 (95%CI = 4.90-7.00) and 5.62h (95%CI = 4.87-6.36) respectively. Medical students used their smartphones mostly for text messaging, followed by photo-sharing or social networking. Its usage for medical education remains unclear.ConclusionThe prevalence of poor sleep and smartphone addiction in medical students was 57% and 39% respectively, with a correlation index of 0.30. Medical students commonly used the smartphone for text-messaging, photo-sharing or social networking, averaging 4.9 hours daily.

Abstract The population is rapidly aging worldwide, and there is an age-related decline in muscle mass. Therefore, it is important to examine the prevalence and associated factors of low appendicular skeletal muscle mass index (ASMI) in older adults. The objectives of this cross-sectional study were (i) to determine the prevalence of low ASMI (ASM/height2) and (ii) to identify factors associated with low ASMI. This study included 1211 community-dwelling adults aged ≥ 65 years. Low ASMI was defined as

Abstract Background Chronic pruritus (CP), itch lasting more than 6 weeks, is common in community‐dwelling older adults. Understanding their illness perception allows the attending physician to develop a personalised care plan to mitigate CP. Aim This study explores the illness perception of CP among older Asian adults in an urban community. Design Qualitative research was conducted, framed by the Common‐Sense Model of self‐regulation (CSM). Through in‐depth interviews (IDIs), qualitative data were gathered from Asian patients with CP, and then a thematic analysis was carried out. The emergent themes were grouped according to the five domains of CSM: ‘identity’, ‘cause’, ‘time’, ‘controllability’ and ‘consequence’. Setting and Patients IDIs were conducted in a Singapore public primary care clinic before the data were saturated. Results The CSM domains illustrate the illness perception of CP. CP was identified as a ‘problem’ rather than a disease and was often described in metaphor. Patients' perception of the cause was diverse due to the lack of provision of a clear explanation by their physicians. They opined that CP continued indefinitely. Without definite time to resolution, patients adapted their help‐ and health‐seeking behaviours to control it. The consequences included therapeutic experimentation, alternative therapy, self‐isolation, avoidance behaviours, emotional disturbance and dermatological complications. Conclusion and Patient Contribution Patients provided information on their perception of CP, which aligned with the CSM. A multipronged approach is needed to deliver holistic and personalised care to patients with CP, providing clarity on its natural progression, to set their expectations on its timeline, treatment effectiveness and undertake appropriate behaviour modification to adapt to its chronicity.

BackgroundWomen of childbearing age may face unintended pregnancy (UP). They are usually referred by primary care professionals (PCPs) to gynecologists to manage their UP in countries where abortion is legalized. The study aimed to determine the prevalence, demographic profiles, and associated factors of women in a developed community seeking referrals from PCPs for their UP.MethodsThe sociodemographic and clinical data were extracted from the electronic medical records of pregnant multi-ethnic Asian women at eight Singapore public primary care clinics from July 2017 to June 2020. Their demographic profiles were reviewed and compared among women of different age bands using appropriate statistical tests. Logistic regression was used to identify the factors associated with UP referrals.ResultsAmong 9,794 gravid women, 974 of them requested gynecologist referrals to terminate UP over the 3-year period, constituting a prevalence of 9.94%. The mean age of women requesting such referrals was 29.7 ± 7 years. There were 10.7% with more than one prior unintended pregnancy and 15.7% were foreigners. The majority of these women were married, neither required social assistance nor had comorbidities. Only 2.9% of them were known to be prescribed contraceptives. A multivariable logistic regression analysis showed that women of Indian ethnicity, single, aged below 20 years and above 40 years, were more likely to request referrals for UP.ConclusionOne in 10 gravid women had sought referrals for UP, especially adolescents and older women, and Indian ethnicity. An accessible community-based healthcare service to educate and counsel women on family planning is urgently needed to reduce the incidence of UP.

Objective Dengue is endemic but vaccination against it is optional in tropical Singapore. Despite vector control measures to curb mosquito breeding, dengue infection continues to be prevalent. A serious game has been developed to raise the community awareness of dengue vector control programme among residents in Singapore. The study aimed to evaluate the effectiveness of this serious game on the knowledge, attitude and practice (KAP) in dengue prevention among adults. It also determined their willingness to be vaccinated against dengue. Methods A randomised controlled trial was conducted among volunteer adults who were visiting a regional primary care clinic in Sengkang, Singapore. 400 participants were randomly allocated to receive information regarding dengue prevention from either playing a serious game (intervention) or visiting a dengue prevention website (control). Before and after receiving information on dengue prevention, participants completed a self-administered online questionnaire within a two-week interval to assess the KAP score and their interest to vaccinate against dengue. Participants, who played serious game, evaluated the game with the System Usability Scale (SUS). Results A total of 374 participants, comprising of 178 participants (89%) from intervention group and 196 participants (98%) from control group, completed both questionnaires. 157 (78.5%) participants in the intervention group completed playing the serious game. Participants in both groups had increased KAP score from baseline, but the mean difference in score (SD) was greater when assessing participants’ daily practice towards dengue prevention in the serious game group compared to the control group (1.0 (2.8) vs 0.3 (1.9), p = .009). There was a positive correlation (rho = 0.275) between mean change in KAP score and highest achievement attained within serious game ( p = .001). The mean SUS (SD) was 61.8 (19.2) among participants who played the serious game. 84.2% of the study population was willing to undertake the dengue vaccination at baseline. Participants in both groups had increased proportion of participants who showed interest in dengue vaccination from baseline but the difference between serious game group and control group were not significant (5.6% vs 2.6%, p = .131). Conclusions Serious game is at least equally effective compared to conventional web-based learning in promoting dengue prevention measures and vaccination intention among adults, and may be considered as a feasible alternative to digitally engage local residents.

Introduction Angiotensin II Receptor Blockers (ARB) are widely utilized in the treatment of hypertension and nephropathy. In March 2019, a mass recall of selected brands of an ARB, losartan due to reported elevated levels of potentially carcinogenic nitrosamine impurities was implemented in a Singapore primary care institution. Objective To describe the crisis management of the mass losartan recall in a public primary healthcare institution in Singapore. Methods The crisis management framework was adapted from the Gonzalez-Herrero and Pratt model. This crisis was managed over three phases: identification of impending crisis based on risk reports by local health authorities, formation of a task force to develop turnaround strategies and measures, implementation and monitoring of the remedial measures. Data to plan and chart implementation was retrieved from the institution databases, including the Electronic Health Intelligence System for patient medical and prescription records, Outpatient Administrative System for reimbursement of medications and other expenditures incurred. An exigency scheme, Losartas® Review Service (LRS), was established to expedite the replacement of the affected medication with another ARB or another anti-hypertensive medication. Results SingHealth Polyclinics completed the recall of 29,794 (92.1%) patients within 14 weeks. The majority of the patients (76.2%) were attended to by doctors, while 16.5% and 7.3% were managed using the LRS and pharmacy respectively. The institution incurred a cost of SGD2,824,760 (estimated SGD95 per patient) to manage the crisis. Conclusion The successful implementation of a mass medication recall hinged on timely intervention, cross-departmental coordination, effective communication and judicious resource allocation.

Background: Multiple COVID-19 vaccines have been approved for use in adolescents; these vaccines play a critical role in limiting the transmission and impact of COVID-19. This systematic review aims to summarize the willingness of adolescents aged 10 to 19 years to receive the COVID-19 vaccination and the factors influencing their decision. Methods: A search of literature published between January 2018 and August 2022 was performed in Medline©, EMBASE©. and CINAHL© electronic databases. Studies published in English that assessed adolescents’ intentions to receive the COVID-19 vaccine were included. Qualitative studies and those unrelated to the COVID-19 vaccine were excluded. The study was conducted based on the PRISMA guidelines. Results: Of the 1074 articles retrieved, 13 were included in the final review. Most studies were conducted in the US (n = 3) and China (n = 3). The pooled prevalence of COVID-19 vaccine acceptance among adolescents was 63% (95% CI: 52–73%). Factors influencing intent to vaccinate were divided into five categories: “Socio-demographic determinants”; “Communication about COVID-19 pandemic and vaccination”; “COVID-19 vaccine and related issues”; “COVID-19 infection and related issues” and “Other determinants”. The enablers were sociodemographic factors including older age, higher education level, good health perception, and parental norms in terms of parental vaccination acceptance; perceived vaccine effectiveness and safety; a desire to protect themselves and others; recent vaccination; and anxiety. The barriers were concerns over vaccine effectiveness, safety, and long-term side effects; low perceived necessity and risk of infection; and needle phobia. Conclusions: This review highlighted that adolescents’ intent to vaccinate is driven by a desire to protect themselves and others. However, concerns over vaccine effectiveness, safety, and long-term side effects hinder COVID-19 vaccine uptake. To improve vaccination acceptance, policymakers should address adolescents’ concerns via more targeted public health messaging, while schools should leverage peer norms to positively influence vaccination intent.

Abstract Background Clinical risk prediction models (CRPMs) use patient characteristics to estimate the probability of having or developing a particular disease and/or outcome. While CRPMs are gaining in popularity, they have yet to be widely adopted in clinical practice. The lack of explainability and interpretability has limited their utility. Explainability is the extent of which a model’s prediction process can be described. Interpretability is the degree to which a user can understand the predictions made by a model. Methods The study aimed to demonstrate utility of patient similarity analytics in developing an explainable and interpretable CRPM. Data was extracted from the electronic medical records of patients with type-2 diabetes mellitus, hypertension and dyslipidaemia in a Singapore public primary care clinic. We used modified K-nearest neighbour which incorporated expert input, to develop a patient similarity model on this real-world training dataset (n = 7,041) and validated it on a testing dataset (n = 3,018). The results were compared using logistic regression, random forest (RF) and support vector machine (SVM) models from the same dataset. The patient similarity model was then implemented in a prototype system to demonstrate the identification, explainability and interpretability of similar patients and the prediction process. Results The patient similarity model (AUROC = 0.718) was comparable to the logistic regression (AUROC = 0.695), RF (AUROC = 0.764) and SVM models (AUROC = 0.766). We packaged the patient similarity model in a prototype web application. A proof of concept demonstrated how the application provided both quantitative and qualitative information, in the form of patient narratives. This information was used to better inform and influence clinical decision-making, such as getting a patient to agree to start insulin therapy. Conclusions Patient similarity analytics is a feasible approach to develop an explainable and interpretable CRPM. While the approach is generalizable, it can be used to develop locally relevant information, based on the database it searches. Ultimately, such an approach can generate a more informative CRPMs which can be deployed as part of clinical decision support tools to better facilitate shared decision-making in clinical practice.

Abstract Background The COVID-19 pandemic led to the implementation of various non-pharmaceutical interventions (NPI) as the Singapore government escalated containment efforts from DORSCON Orange to Circuit Breaker. NPI include mandatory mask wearing, hand hygiene, social distancing, and closure of schools and workplaces. Considering the similar mode of transmission of COVID-19 and other pathogens related to acute respiratory infections (ARI), the effects of NPI could possibly lead to decreased ARI attendances in the community. This study aims to determine the year-on-year and weekly changes of ARI attendances across a cluster of polyclinics following the implementation of NPI. Methods The effect of the nation-wide measures on the health-seeking behaviour of the study population was examined over three periods: (1) 9 weeks prior to the start of Circuit Breaker (DORSCON Orange period), (2) 8 weeks during the Circuit Breaker, and (3) 9 weeks after easing of Circuit Breaker. Data on ARI attendances for the corresponding periods in 2019 were also extracted for comparison and to assess the seasonal variations of ARI. The average weekly workday ARI attendances were compared with those of the preceding week using Wilcoxon signed rank test. Results ARI attendances dropped steadily throughout the study period and were 50–80% lower than in 2019 since Circuit Breaker. They remained low even after Circuit Breaker ended. Positivity rate for influenza-like illnesses samples in the community was 0.0% from the last week of Circuit Breaker to end of study period. Conclusions NPI and public education measures during DORSCON Orange and Circuit Breaker periods appear to be associated with the health-seeking behaviour of the public. Changing levels of perceived susceptibility, severity, benefits and barriers, and widespread visual cues based on the Health Belief Model may account for this change. Understanding the impact of NPI and shifts in the public’s health-seeking behaviour will be relevant and helpful in the planning of future pandemic responses.