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Fong C, Kueh WL, Lew SJW, Ho BCH, Wong YL, Lau YH, Chia YW, Tan HL, Seet YHC, Siow WT, MacLaren G, Agrawal R, Lim TJ, Lim SL, Lim TW, Ho VK, Soh CR, Sewa DW, Loo CM, Khan FA, Tan CK, Gokhale RS, Siau C, Lim NLSH, Yim CF, Venkatachalam J, Venkatesan K, Chia NCH, Liew MF, Li G, Li L, Myat SM, Zena Z, Zhuo S, Yueh LL, Tan CSF, Ma J, Yeo SL, Chan YH, Phua J. Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study. J Intensive Care 2024; 12:13. [PMID: 38528556 DOI: 10.1186/s40560-024-00725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches. METHODS This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality. RESULTS There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis. CONCLUSIONS Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.
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Affiliation(s)
- Clare Fong
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore.
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Wern Lunn Kueh
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Sennen Jin Wen Lew
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Benjamin Choon Heng Ho
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yu-Lin Wong
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yew Woon Chia
- Cardiac Intensive Care Unit, Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Hui Ling Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Ying Hao Christopher Seet
- Department of Neurology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wen Ting Siow
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Graeme MacLaren
- Cardiothoracic ICU, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Rohit Agrawal
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Tian Jin Lim
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Department of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Pre-Hospital and Emergency Research Center, Duke-NUS Medical School, 8 College Rd, Singapore, 16985, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Vui Kian Ho
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
- Department of Surgical Intensive Care, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chai Rick Soh
- Department of Anaesthesiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chian Min Loo
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Roshni Sadashiv Gokhale
- Department of Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chuin Siau
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Noelle Louise Siew Hua Lim
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chik-Foo Yim
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Jonathen Venkatachalam
- Department of Respiratory and Critical Care Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Kumaresh Venkatesan
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Naville Chi Hock Chia
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
- Yong Loo Lin School of Medicine, 10 Medical Dr, Singapore, 117597, Singapore
- Lee Kong Chian School of Medicine, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - Mei Fong Liew
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Guihong Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Li Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Su Mon Myat
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Zena Zena
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Shuling Zhuo
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Ling Ling Yueh
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Caroline Shu Fang Tan
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jing Ma
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Siew Lian Yeo
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
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Griva K, Chua ZY, Lai LY, Xu SJ, Bek ESJ, Lee ES. Pharmacist-led medication reconciliation service for patients after discharge from tertiary hospitals to primary care in Singapore: a qualitative study. BMC Health Serv Res 2024; 24:357. [PMID: 38509565 PMCID: PMC10956343 DOI: 10.1186/s12913-024-10830-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 03/05/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Medication discrepancies commonly occur when patients are transferred between care settings. Despite the presence of medication reconciliation services (MRS), medication discrepancies are still prevalent, which has clinical costs and implications. This study aimed to explore the perspectives of various stakeholders on how the MRS can be optimized in Singapore. METHODS This is a descriptive qualitative study. Semi-structured interviews with 30 participants from the National Healthcare Group, including family physicians (N = 10), pharmacists (N = 10), patients recently discharged from restructured hospitals (N = 7) and their caregivers (N = 3) were conducted. All transcribed interviews were coded independently by three coders and inductive thematic analysis approach was used. RESULTS Five core themes were identified. (1) The MRS enhanced healthcare services in various aspects including efficiency and health literacy; (2) There were several challenges in delivering the MRS covering processes, technology and training; (3) Issues with suitable patient selection and follow-up; (4) Barriers to scaling up of MRS that involve various stakeholders, cross-sector integration and environmental restrictions; and finally (5) Role definition of the pharmacist to all the stakeholders. CONCLUSION This study identified the role of MRS in enhancing healthcare services and explored the challenges encountered in the provision of MRS from family physicians, pharmacists, patients and their caregivers. These findings supported the need for a shift of MRS towards a more comprehensive medication review model. Future improvement work to the MRS can be conducted based on the findings.
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Affiliation(s)
- Konstadina Griva
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Zi Yang Chua
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Lester Yousheng Lai
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | | | | | - Eng Sing Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
- Clinical Research Unit, National Healthcare Group Polyclinics, 3 Fusionopolis Link Nexus@one-north (South Tower), #06-13, Singapore, 138543, Singapore.
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Soh JGS, Mukhopadhyay A, Mohankumar B, Quek SC, Tai BC. Predictors of frequency of 1-year readmission in adult patients with diabetes. Sci Rep 2023; 13:22389. [PMID: 38104137 PMCID: PMC10725424 DOI: 10.1038/s41598-023-47339-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 11/12/2023] [Indexed: 12/19/2023] Open
Abstract
Diabetes mellitus (DM) is the third most common chronic condition associated with frequent hospital readmissions. Predictors of the number of readmissions within 1 year among patients with DM are less often studied compared with those of 30-day readmission. This study aims to identify predictors of number of readmissions within 1 year amongst adult patients with DM and compare different count regression models with respect to model fit. Data from 2008 to 2015 were extracted from the electronic medical records of the National University Hospital, Singapore. Inpatients aged ≥ 18 years at the time of index admission with a hospital stay > 24 h and survived until discharge were included. The zero-inflated negative binomial (ZINB) model was fitted and compared with three other count models (Poisson, zero-inflated Poisson and negative binomial) in terms of predicted probabilities, misclassification proportions and model fit. Adjusted for other variables in the model, the expected number of readmissions was 1.42 (95% confidence interval [CI] 1.07 to 1.90) for peripheral vascular disease, 1.60 (95% CI 1.34 to 1.92) for renal disease and 2.37 (95% CI 1.67 to 3.35) for Singapore residency. Number of emergency visits, number of drugs and age were other significant predictors, with length of stay fitted as a zero-inflated component. Model comparisons suggested that ZINB provides better prediction than the other three count models. The ZINB model identified five patient characteristics and two comorbidities associated with number of readmissions. It outperformed other count regression models but should be validated before clinical adoption.
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Affiliation(s)
- Jade Gek Sang Soh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
- Health and Social Sciences, Singapore Institute of Technology, Singapore, Singapore.
| | - Amartya Mukhopadhyay
- Respiratory and Critical Care Medicine, National University Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine National University of Singapore, Singapore, Singapore
- Medical Affairs, Alexandra Hospital, Singapore, Singapore
| | | | - Swee Chye Quek
- Department of Pediatric Cardiology, National University Hospital, Singapore, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine National University of Singapore, Singapore, Singapore
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Chay J, Tang RWC, Tan TE, Chan CM, Mathur R, Lee BJH, Chan HH, Sim SSKP, Farooqui S, Teo KYC, Fenwick EK, Lamoureux EL, Cheung CMG, Fenner BJ. The economic burden of inherited retinal disease in Singapore: a prevalence-based cost-of-illness study. Eye (Lond) 2023; 37:3827-3833. [PMID: 37301937 PMCID: PMC10698171 DOI: 10.1038/s41433-023-02624-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/17/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE To assess the economic impact of inherited retinal disease (IRD) among Singaporeans. METHODS IRD prevalence was calculated using population-based data. Focused surveys were conducted for sequentially enrolled IRD patients from a tertiary hospital. The IRD cohort was compared to the age- and gender-matched general population. Economic costs were expanded to the national IRD population to estimate productivity and healthcare costs. RESULTS National IRD caseload was 5202 cases (95% CI, 1734-11273). IRD patients (n = 95) had similar employment rates to the general population (67.4% vs. 70.7%; p = 0.479). Annual income was lower among IRD patients than the general population (SGD 19,500 vs. 27,161; p < 0.0001). Employed IRD patients had lower median income than the general population (SGD 39,000 vs. 52,650; p < 0.0001). Per capita cost of IRD was SGD 9382, with a national burden of SGD 48.8 million per year. Male gender (beta of SGD 6543, p = 0.003) and earlier onset (beta of SGD 150/year, p = 0.009) predicted productivity loss. Treatment of the most economically impacted 10% of IRD patients with an effective IRD therapy required initial treatment cost of less than SGD 250,000 (USD 188,000) for cost savings to be achieved within 20 years. CONCLUSIONS Employment rates among Singaporean IRD patients were the same as the general population, but patient income was significantly lower. Economic losses were driven in part by male patients with early age of onset. Direct healthcare costs contributed relatively little to the financial burden.
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Affiliation(s)
- Junxing Chay
- Health Services & Systems Research Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | | | - Tien-En Tan
- Singapore Eye Research Institute, Singapore, Singapore
- Department of Medical Retina, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Choi Mun Chan
- Singapore Eye Research Institute, Singapore, Singapore
- Department of Medical Retina, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Ranjana Mathur
- Singapore Eye Research Institute, Singapore, Singapore
- Department of Medical Retina, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Brian J H Lee
- Department of Medical Retina, Singapore National Eye Centre, Singapore, Singapore
| | - Hiok Hong Chan
- Singapore Eye Research Institute, Singapore, Singapore
- Department of Medical Retina, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Shaun S K P Sim
- Singapore Eye Research Institute, Singapore, Singapore
- Department of Medical Retina, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Saadia Farooqui
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
- Department of Paediatric Ophthalmology, Singapore National Eye Centre, Singapore, Singapore
| | - Kelvin Y C Teo
- Singapore Eye Research Institute, Singapore, Singapore
- Department of Medical Retina, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Eva K Fenwick
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Ecosse L Lamoureux
- Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Chui Ming Gemmy Cheung
- Singapore Eye Research Institute, Singapore, Singapore
- Department of Medical Retina, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Beau J Fenner
- Singapore Eye Research Institute, Singapore, Singapore.
- Department of Medical Retina, Singapore National Eye Centre, Singapore, Singapore.
- Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore.
- Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
- Institute of Vision Research, University of Iowa, Iowa City, IA, USA.
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van Ede AFTM, Minderhout RN, Stein KV, Bruijnzeels MA. How to successfully implement population health management: a scoping review. BMC Health Serv Res 2023; 23:910. [PMID: 37626327 PMCID: PMC10464069 DOI: 10.1186/s12913-023-09915-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Despite international examples, it is unclear for multisector initiatives which want to sustainably improve the health of a population how to implement Population Health Management (PHM) and where to start. Hence, the main purpose of this research is to explore current literature about the implementation of PHM and organising existing knowledge to better understand what needs to happen on which level to achieve which outcome. METHODS A scoping review was performed within scientific literature. The data was structured using Context-Mechanism-Outcome, the Rainbow model of integrated care and six elements of PHM as theoretical concepts. RESULTS The literature search generated 531 articles, of which 11 were included. Structuring the data according to these three concepts provided a framework that shows the skewed distribution of items that influence the implementation of PHM. It highlights that there is a clear focus on normative integration on the organisational level in 'accountable regional organisation'. There is less focus on the normative integration of 'cross domain business model', 'integrated data infrastructure', and 'population health data analytics', and overall the perspective of citizen and professionals, indicating possible gaps of consideration. CONCLUSIONS A first step is taken towards a practical guide to implement PHM by illustrating the depth of the complexity and showing the partial interrelatedness of the items. Comparing the results with existing literature, the analysis showed certain gaps that are not addressed in practice, but should be according to other frameworks. If initiators follow the current path in literature, they may be missing out on some important components to achieve proper implementation of PHM.
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Affiliation(s)
- A F T M van Ede
- Department of Public Health and Primary Care/ Health Campus The Hague, Leiden University Medical Centre, The Hague, The Netherlands.
| | - R N Minderhout
- Department of Public Health and Primary Care/ Health Campus The Hague, Leiden University Medical Centre, The Hague, The Netherlands
| | - K V Stein
- Department of Public Health and Primary Care/ Health Campus The Hague, Leiden University Medical Centre, The Hague, The Netherlands
| | - M A Bruijnzeels
- Department of Public Health and Primary Care/ Health Campus The Hague, Leiden University Medical Centre, The Hague, The Netherlands
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Phang SKA, Lin M, Kho YX, Toh RJR, Kuah TT, Lai YF, Xie JK. Community hospitals of the future-challenges and opportunities. FRONTIERS IN HEALTH SERVICES 2023; 3:1168429. [PMID: 37621376 PMCID: PMC10445538 DOI: 10.3389/frhs.2023.1168429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023]
Abstract
Background Medical training through specialization and even subspecialization has contributed significantly to clinical excellence in treating single acute conditions. However, the needs of complex patients go beyond single diseases, and there is a need to identify a group of generalists who are able to deliver cost-effective, holistic care to patients with multiple comorbidities and multi-faceted needs. Community hospitals (CHs) are a critical part of Singapore's shift toward a community-centric care model as the population ages. Community Hospitals of the Future ("CHoF") represent a series of emerging conversations around approaches to reimagine and redesign care delivery in a CH setting in response to changing care needs. Methods An environmental scan in the CH landscape using semi-structured interviews was conducted with 26 senior management, management, and working-level staff from seven community hospitals in Singapore. This environmental scan aims to understand the current barriers and future opportunities for CHs; to guide how CHs would have to shift in terms of (i) care delivery and resourcing, (ii) information flow, and (iii) financing; and to conceptualize CHoF to meet the changing care needs in Singapore. Findings The analysis of all transcripts revealed four broad sections of themes: (i) current care delivery in CHs, (ii) current challenges of CHs, (iii) future opportunities, and (iv) challenges in reimagining CHs. An emerging theme regarding the current key performance indicators used also surfaced. Resource limitations and financing structure of CH surfaced as limitations to expanding its capability. However, room for expansion of CH roles tapping on the current expertise were acknowledged and shared. Conclusion With the current issues of (i) rapidly aging population, (ii) specialist-centric healthcare system, and (iii) fragmentation of care ecosystem, there is a need to further understand how CHoF can be modeled to better tackle them. Therefore, several important questions have been devised to land us in a microscopic view on how to develop CHoF in the right constructs. Demographic changes, patient segmentation, service and regulatory parameters, patient's perspective, care delivery, and financial levers (or lack of) are some of the categories that the interview questions looked into. Therefore, the data gathered would be used to guide and refine the concept of CHoF.
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Affiliation(s)
| | - Ming Lin
- Nanyang Technological University, Singapore, Singapore
| | - Yong Xiang Kho
- Chua Thian Poh Community Leadership Centre, National University of Singapore, Singapore, Singapore
| | - Rui Jie Rachel Toh
- Chua Thian Poh Community Leadership Centre, National University of Singapore, Singapore, Singapore
| | - Ting Ting Kuah
- Chua Thian Poh Community Leadership Centre, National University of Singapore, Singapore, Singapore
| | - Yi Feng Lai
- MOH Office for Healthcare Transformation, Singapore, Singapore
| | - JiaJing Kim Xie
- MOH Office for Healthcare Transformation, Singapore, Singapore
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Tan JK, Zhang X, Cheng D, Leong IYO, Wong CS, Tey J, Loh SC, Soh EF, Lim WY. Using the Johns Hopkins ACG Case-Mix System for population segmentation in a hospital-based adult patient population in Singapore. BMJ Open 2023; 13:e062786. [PMID: 36997258 PMCID: PMC10069494 DOI: 10.1136/bmjopen-2022-062786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVE Population health management involves risk characterisation and patient segmentation. Almost all population segmentation tools require comprehensive health information spanning the full care continuum. We assessed the utility of applying the ACG System as a population risk segmentation tool using only hospital data. DESIGN Retrospective cohort study. SETTING Tertiary hospital in central Singapore. PARTICIPANTS 100 000 randomly selected adult patients from 1 January to 31 December 2017. INTERVENTION Hospital encounters, diagnoses codes and medications prescribed to the participants were used as input data to the ACG System. PRIMARY AND SECONDARY OUTCOME MEASURES Hospital costs, admission episodes and mortality of these patients in the subsequent year (2018) were used to assess the utility of ACG System outputs such as resource utilisation bands (RUBs) in stratifying patients and identifying high hospital care users. RESULTS Patients placed in higher RUBs had higher prospective (2018) healthcare costs, and were more likely to have healthcare costs in the top five percentile, to have three or more hospital admissions, and to die in the subsequent year. A combination of RUBs and ACG System generated rank probability of high healthcare costs, age and gender that had good discriminatory ability for all three outcomes, with area under the receiver-operator characteristic curve (AUC) values of 0.827, 0.889 and 0.876, respectively. Application of machine learning methods improved AUCs marginally by about 0.02 in predicting the top five percentile of healthcare costs and death in the subsequent year. CONCLUSION A population stratification and risk prediction tool can be used to appropriately segment populations in a hospital patient population even with incomplete clinical data.
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Affiliation(s)
- Joshua Kuan Tan
- Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Xiaojin Zhang
- Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Dawn Cheng
- Population Health Office, Tan Tock Seng Hospital, Singapore
| | | | | | - Jeannie Tey
- Planning and Development, Tan Tock Seng Hospital, Singapore
| | - Shu Ching Loh
- Division of Central Health, Tan Tock Seng Hospital, Singapore
| | | | - Wei Yen Lim
- Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
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Chua CMS, Ko SQ, Lai YF, Lim YW, Shorey S. Perceptions of Stakeholders Toward "Hospital at Home" Program in Singapore: A Descriptive Qualitative Study. J Patient Saf 2022; 18:e606-e612. [PMID: 34406987 DOI: 10.1097/pts.0000000000000890] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hospital at Home (HaH) programs have been shown to improve quality of care and patient satisfaction, and reduce bed occupancy rate in hospitals. Despite the prevalence of HaH in Western countries, studies in Asia are limited and the perception of HaH remains underexplored in Asian context. Understanding the perceptions of stakeholders is vital before implementing HaH in any new settings. Thus, the aim of this study is to explore the perceptions of referring physicians, care providers, patients, and caregivers on HaH programs in a multiracial country such as in Singapore. METHODS This study used a descriptive qualitative design. Participants from 2 tertiary hospitals in Singapore, including 13 referring physicians, 10 care providers, 15 patients, and 3 caregivers, were interviewed between June 2020 and September 2020. Data were analyzed using inductive thematic analysis. RESULTS The overarching theme titled "The stakeholders' perception on HaH" was pillared by 4 main themes: (1) patients suitable for HaH; (2) perceived advantages and benefits of HaH; (3) perceived risks, anxiety, and concerns about HaH; and (4) potential enablers of HaH. Overall, the findings reported that most of the stakeholders embraced HaH. Timely medical interventions and support from care providers were reportedly important factors to maintain patient safety and quality of care. The importance of having adequate resources and sound financing mechanisms to develop a successful HaH program was also highlighted. CONCLUSIONS This study offered insights into HaH from the perspectives of stakeholders in Singapore and facilitate the planning of future HaH pilot programs in multiracial Singapore and other Asian countries.
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Affiliation(s)
- Crystal Min Siu Chua
- From the Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore
| | - Stephanie Qianwen Ko
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital
| | | | | | - Shefaly Shorey
- From the Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore
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9
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Healthcare Management: A Bibliometric Analysis Based on the Citations of Research Articles Published between 1967 and 2020. Healthcare (Basel) 2022; 10:healthcare10030555. [PMID: 35327034 PMCID: PMC8954756 DOI: 10.3390/healthcare10030555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/21/2022] [Accepted: 03/14/2022] [Indexed: 02/05/2023] Open
Abstract
The purpose of this study is to analyse the trends manifested in research literature from the field of healthcare management, with emphasis on bibliometric features and different influencing factors. For this, a search was conducted of nine academic databases between January and May 2021. Article features were registered in our database after first applying the validation criteria used for their inclusion. Then, data regarding the publication of the included articles were collected. The analysis focused on trends over time, topic, and journals in which they were published. Moreover, the effect of some factors on the citation of articles was analysed. Our results showed that the 250 analysed articles were published in 139 journals, and many of were by researchers affiliated with universities in the United States. Over time, the publication of analysed articles and their number of citations registered a continuous increase. The most common topics of focus were healthcare management systems and their challenges. In our study, we identified factors that significantly affect citation number, such as number of years since publication, the number of words in the title, and the number of authors of an article. In addition, major gaps were identified, as were new unresolved challenges that can trigger new research ideas.
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10
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Alonazi WB, Altuwaijri EA. Health Policy Development During COVID-19 in Saudi Arabia: Mixed Methods Analysis. Front Public Health 2022; 9:801273. [PMID: 35360666 PMCID: PMC8963949 DOI: 10.3389/fpubh.2021.801273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/13/2021] [Indexed: 12/23/2022] Open
Abstract
Healthcare systems are increasingly required to utilize effective approaches, apply evidence-based practice, and consequently sustain successful strategic management. Document analysis provides insights into the effective management tools applied by agencies to respond to crises. This article provides a practical exploration of how the Saudi health authority applied effective measures to eventually reduce the administrative and clinical consequences while managing the COVID-19 pandemic. The conceptual descriptive framework was based on health policy triangle of Walt and Gilson. Official reports and supporting documents issued by the Saudi government toward COVID-19 were operationally analyzed. Moreover, five healthcare professional experts were invited in a semistructured interview to assess the strategic steps that have been utilized to minimize the health risk by conducting a healthcare risk analysis. Various documents showed that two major entities were responsible for managing regulations and medications of COVID-19 in addition to six other entities that were partially involved. Although each entity was approved to work independently, their efforts were cohesively associated with each other. Most documents were well-applied on personal, social, organizational, and national strata. However, it is unclear how lessons identified became affirmative, while the collaboration remains vague, especially under the emergence of a new entity such as the Public Health Authority. Healthcare professional experts also positively supported the effectiveness of such policies to confront COVID-19 through the following three domains: health guidelines, utilizing simulation (telehealth/telecommunication) services, and ensuring continuity of services.
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Affiliation(s)
- Wadi B. Alonazi
- Health Administration Department, College of Business Administration, King Saud University, Riyadh, Saudi Arabia
- *Correspondence: Wadi B. Alonazi
| | - Eman A. Altuwaijri
- Department of Administrative and Human Sciences, College of Applied Studies and Community Service, King Saud University, Riyadh, Saudi Arabia
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11
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Yan C, Liao H, Ma Y, Wang J. The Impact of Health Care Reform Since 2009 on the Efficiency of Primary Health Services: A Provincial Panel Data Study in China. Front Public Health 2021; 9:735654. [PMID: 34746081 PMCID: PMC8569255 DOI: 10.3389/fpubh.2021.735654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Primary health care (PHC) is an important part of health systems in the world and in China. To improve the efficiency of PHC institutions (PHCIs), many countries have implemented reforms, including China's health care reform since 2009. This study aims to evaluate the impact of this reform on the efficiency of PHCIs from the perspective of the whole health system. Methods: Data were collected from China Health Statistical Yearbooks and China Statistical Yearbooks published from 2005 to 2019. By taking the number of beds, health technicians and PHCIs as inputs and the proportion of diagnosis, treatment and admission in PHCIs as outputs, Malmquist DEA was used to evaluate the efficiency change of PHCIs, and panel data regression was performed to analyze the impact of the reform and other factors on such efficiency. The interaction between reform and economic level was also estimated. Results: The MPI in Beijing, Tianjin, Shanghai, Hunan, and Guangdong improved after the reform. The efficiency improvement in Beijing, Tianjin and Shanghai is mainly reflected in the growth of TC, whereas the efficiency improvement in Guangdong and Hunan is mainly reflected in the growth of EC. Meanwhile, the EC and TC in Hebei, Heilongjiang, Shandong, and other provinces deteriorated. The deterioration of MPI in Shanxi, Inner Mongolia and Jilin was mainly attributed to EC. while the deterioration of MPI in Liaoning, Anhui, and Fujian provinces is mainly attributed to TC. Since 2009, the reform exerted a negative impact on MPI (β = -0.06; P < 0.01), TC (β = -0.048; P < 0.01) and EC (β = -0.03; P < 0.01). And such negative impact was weaker in economically developed areas (β = 0.076; P < 0.01). Conclusions: Attention should be paid to future reforms: China should continue investing in PHCIs, establish a structurally integrated and functionally complementary delivery system and promote the coordination of reform policies to avoid the adverse impacts of other reform policies on PHCIs.
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Affiliation(s)
- Chaoyang Yan
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Liao
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Ma
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Wang
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,The Key Research Institute of Humanities and Social Science of Hubei Province, Huazhong University of Science and Technology, Wuhan, China.,Health Poverty Alleviation Center, Institute for Poverty Reduction and Development, Huazhong University of Science and Technology, Wuhan, China
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12
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O'Brien N, Durkin M, Lachman P. Lessons post-COVID from national and international approaches to safety and quality in healthcare. Future Healthc J 2021; 8:e602-e608. [PMID: 34888449 PMCID: PMC8651324 DOI: 10.7861/fhj.2021-0158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The COVID-19 pandemic has been a challenge as well as an opportunity for healthcare. The pandemic has exposed the inherent weaknesses in health systems globally while, at the same time, revealing strengths on which post-pandemic health systems can be built. We propose lessons on improving quality and safety post-pandemic from a global perspective based on recent policy publications and our global experience. Nine possible lessons are discussed. These lessons can ensure that healthcare does not return to the old normal, but rather builds on what we have learnt as we deliver on the Sustainable Development Goals and universal health coverage. Quality and safety are an essential component of healthcare strategy. Post-pandemic systems require a transparent compassionate culture, with integration of care at its core. The workforce must be trained in the skills to improve care, and patient and healthcare worker protection (both physically and psychologically) needs to be a given. Any development of systems will best be co-produced with the people who receive and deliver care in an equal partnership. Finally, the new systems need to be conscious of emerging threats (such as the challenge of climate change), building sustainable health systems that also address the structural inequities that currently exist.
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Affiliation(s)
- Niki O'Brien
- Institute of Global Health Innovation, London, UK and Imperial College London, London, UK
| | - Mike Durkin
- and academic lead, Global Patient Safety Collaborative, London, UK
| | - Peter Lachman
- Royal College of Physicians of Ireland, Dublin, Ireland
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13
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Zheng S, He A, Yu Y, Jiang L, Liang J, Wang P. Research trends and hotspots of health-related quality of life: a bibliometric analysis from 2000 to 2019. Health Qual Life Outcomes 2021; 19:130. [PMID: 33892744 PMCID: PMC8063463 DOI: 10.1186/s12955-021-01767-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 04/09/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The number of research articles on health-related quality of life (HRQoL) has been strikingly increasing. This study aimed to explore the general trends and hotspots of HRQoL. METHODS Based on the Web of Science database, research on HRQoL published between 2000 and 2019 were identified. A bibliometric analysis was performed based on the number of articles, citations, published journals, authors' addresses, and keywords. Descriptive analysis, visualization of geographic distribution and keyword clustering analysis were applied to the collected data. RESULTS The annual number of articles showed growth over the past twenty years, but the annual total citations and annual citations per article were both in decreasing trends. Articles about HRQoL were more likely to be published in journals of multi-subject categories. The HRQoL research was mainly distributed across North America and Europe throughout the twenty years and ushered in a vigorous development worldwide after 2015. Cooperation strength between domestic institutions was much greater than that of international institutions. HRQoL research had six concentrated clusters: HRQoL, Depression, Obesity, Disability, Oncology, Fatigue. CONCLUSION This study provided an overall perspective of global research trends and hotspots in HRQoL, and a potential insight for future research. HRQoL research had experienced significant increasing development during 2000-2019, especially the HRQoL measurement instruments, however, there were significant regional disparities in scientific output in HRQoL.
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Affiliation(s)
- Si Zheng
- School of Health Sciences, Wuhan University, NO. 115 Donghu Road, Wuhan City, 430071, China
| | - Anqi He
- School of Health Sciences, Wuhan University, NO. 115 Donghu Road, Wuhan City, 430071, China
| | - Yan Yu
- School of Health Sciences, Wuhan University, NO. 115 Donghu Road, Wuhan City, 430071, China
| | - Lingling Jiang
- Wuhan Library, Chinese Academy of Science, NO. 25 West of XiaoHonghan, Wuhan City, 430071, China
| | - Jing Liang
- School of Health Sciences, Wuhan University, NO. 115 Donghu Road, Wuhan City, 430071, China
| | - Peigang Wang
- School of Health Sciences, Wuhan University, NO. 115 Donghu Road, Wuhan City, 430071, China.
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14
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Denning M, Goh ET, Tan B, Kanneganti A, Almonte M, Scott A, Martin G, Clarke J, Sounderajah V, Markar S, Przybylowicz J, Chan YH, Sia CH, Chua YX, Sim K, Lim L, Tan L, Tan M, Sharma V, Ooi S, Winter Beatty J, Flott K, Mason S, Chidambaram S, Yalamanchili S, Zbikowska G, Fedorowski J, Dykowska G, Wells M, Purkayastha S, Kinross J. Determinants of burnout and other aspects of psychological well-being in healthcare workers during the Covid-19 pandemic: A multinational cross-sectional study. PLoS One 2021; 16:e0238666. [PMID: 33861739 PMCID: PMC8051812 DOI: 10.1371/journal.pone.0238666] [Citation(s) in RCA: 176] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 03/21/2021] [Indexed: 01/09/2023] Open
Abstract
The Covid-19 pandemic has placed unprecedented pressure on healthcare systems and workers around the world. Such pressures may impact on working conditions, psychological wellbeing and perception of safety. In spite of this, no study has assessed the relationship between safety attitudes and psychological outcomes. Moreover, only limited studies have examined the relationship between personal characteristics and psychological outcomes during Covid-19. From 22nd March 2020 to 18th June 2020, healthcare workers from the United Kingdom, Poland, and Singapore were invited to participate using a self-administered questionnaire comprising the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS) to evaluate safety culture, burnout and anxiety/depression. Multivariate logistic regression was used to determine predictors of burnout, anxiety and depression. Of 3,537 healthcare workers who participated in the study, 2,364 (67%) screened positive for burnout, 701 (20%) for anxiety, and 389 (11%) for depression. Significant predictors of burnout included patient-facing roles: doctor (OR 2.10; 95% CI 1.49-2.95), nurse (OR 1.38; 95% CI 1.04-1.84), and 'other clinical' (OR 2.02; 95% CI 1.45-2.82); being redeployed (OR 1.27; 95% CI 1.02-1.58), bottom quartile SAQ score (OR 2.43; 95% CI 1.98-2.99), anxiety (OR 4.87; 95% CI 3.92-6.06) and depression (OR 4.06; 95% CI 3.04-5.42). Significant factors inversely correlated with burnout included being tested for SARS-CoV-2 (OR 0.64; 95% CI 0.51-0.82) and top quartile SAQ score (OR 0.30; 95% CI 0.22-0.40). Significant factors associated with anxiety and depression, included burnout, gender, safety attitudes and job role. Our findings demonstrate a significant burden of burnout, anxiety, and depression amongst healthcare workers. A strong association was seen between SARS-CoV-2 testing, safety attitudes, gender, job role, redeployment and psychological state. These findings highlight the importance of targeted support services for at risk groups and proactive SARS-CoV-2 testing of healthcare workers.
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Affiliation(s)
- Max Denning
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Ee Teng Goh
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Benjamin Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Abhiram Kanneganti
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore, Singapore
| | - Melanie Almonte
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Alasdair Scott
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Guy Martin
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Jonathan Clarke
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Viknesh Sounderajah
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Sheraz Markar
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Jan Przybylowicz
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ying Xian Chua
- Pioneer Polyclinic, National University Polyclinic, National University Health System, Singapore, Singapore
| | - Kang Sim
- Institute of Mental Health, Singapore, Singapore
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lucas Lim
- Department of Forensic Psychiatry, Institute of Mental Health, Singapore, Singapore
| | - Lifeng Tan
- Division of Healthy Ageing, Alexandra Hospital, Singapore, Singapore
| | - Melanie Tan
- Department of Geriatric Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Vijay Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shirley Ooi
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Emergency Medicine Department, National University Hospital, Singapore, Singapore
| | | | - Kelsey Flott
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Sam Mason
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Seema Yalamanchili
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Gabriela Zbikowska
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Grazyna Dykowska
- Department of Economics of Health and Medical Law, Medical University of Warsaw, Poland
| | - Mary Wells
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Sanjay Purkayastha
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - James Kinross
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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15
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Lai YF, Leow SY, Lee SYF, Xiong J, Lim CW, Ong BC. General medicine at the frontline of acute care delivery: Comparison with family medicine hospitalist model implementation in Singapore. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/2010105820937747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction This mixed methods study seeks to assess the clinical outcomes and qualitative insights associated with the pragmatic implementation of a general medicine (GM) physician-led inpatient care model, first at Alexandra Hospital (AH) and then at Sengkang General Hospital (SKH), and to compare them with findings reported in an earlier implementation of the family medicine (FM) hospitalist model in Singapore. Methods Anonymous quantitative demographic and clinical data including length of stay, 30-day readmission rate, inpatient mortality rate and gross cost of hospitalisation bills were extracted from the hospital information system. Comparative analyses with the FM hospitalist model and usual care were made. Secondary qualitative data that were gathered focused on increased understanding of the proposed model, its perceived challenges and future opportunities for its implementation. Results The adapted GM care model implemented first at AH and then at SKH seemed to suggest that such a model run by physicians from various backgrounds was capable of producing similarly superior outcomes when compared with the FM hospitalist model piloted in 2011, which was juxtaposed with usual care. With regard to qualitative insights, three findings were reported: (a) perception of and mindset in relation to generalists, which illustrates the barriers to implementing GM; (b) education and training of generalists, which underlines the current lack of adequate supply of GM specialists; and (c) operational issues of care model implementation, which highlights the current mismatches between the prevailing healthcare philosophy and the requirements for successful implementation of the GM care model. Conclusion The success of a GM care model hinges on how it is operationalised. With clear protocols, definitions, and a high level of protocol compliance by healthcare team members, the intended outcomes show promise for replication at other interested sites.
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Affiliation(s)
- Yi Feng Lai
- Office for Healthcare Transformation, Ministry of Health, Singapore
- National University of Singapore, Singapore
- Alexandra Hospital, Singapore
| | | | | | - Jun Xiong
- National University of Singapore, Singapore
| | - Cher Wee Lim
- Office for Healthcare Transformation, Ministry of Health, Singapore
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Surendran S, Foo CD, Tam CH, Ho EQY, Matchar DB, Car J, Koh GCH. The Missed Opportunity of Patient-Centered Medical Homes to Thrive in an Asian Context. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041817. [PMID: 33668610 PMCID: PMC7917999 DOI: 10.3390/ijerph18041817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 11/16/2022]
Abstract
In recent years, there is growing interest internationally to implement patient-centered medical homes (PCMHs), and Singapore is no exception. However, studies understanding the influence of contextual policy factors on the implementation of PCMHs are limited. We conducted 10 semi-structured in-depth interviews with general practitioners working in seven out of the nine PCMHs. Audio recordings were transcribed and analyzed by two study team members in NVivo 12 Software using grounded theory techniques. Power dynamics between the stakeholders and lack of shared decision-making among them in selecting the locale of the PCMH and formulating the practice fee and pharmacy structure were the key factors which negatively affected the implementation of PCMHs on a larger scale. Over time, lack of funding to hire dedicated staff to transfer patients and misalignment of various stakeholders’ interest to other right-siting programs also resulted in low number of patients with chronic conditions and revenue. Countries seeking to implement a successful PCMH may benefit from building trust and relationship between stakeholders, engaging in shared decision-making, ongoing cost-efficiency efforts, and formulating a clear delineation of responsibilities between stakeholders. For a healthcare delivery model to succeed in the primary care landscape, policies should be developed keeping mind the realities of primary care practice.
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Affiliation(s)
- Shilpa Surendran
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
- Correspondence:
| | - Chuan De Foo
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
| | - Chen Hee Tam
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
| | - Elaine Qiao Ying Ho
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
| | - David Bruce Matchar
- Health Services and Systems Research, Duke—NUS Medical School, 8 College Road, Singapore 169857, Singapore;
- Department of Medicine (General Internal Medicine), Duke University School of Medicine, 400 Morris Street 3rd Floor, Durham, NC 27701, USA
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Singapore 308232, Singapore;
| | - Gerald Choon Huat Koh
- Health Systems and Behavioral Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, 12 Science Drive 2, Singapore 117549, Singapore; (C.D.F.); (C.H.T.); (E.Q.Y.H.); (G.C.H.K.)
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Lai YF, Lee SYF, Xiong J, Leow SY, Lim CW, Ong BC. Challenges and opportunities in pragmatic implementation of a holistic hospital care model in Singapore: A mixed-method case study. PLoS One 2021; 16:e0245650. [PMID: 33471837 PMCID: PMC7817047 DOI: 10.1371/journal.pone.0245650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 01/06/2021] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Hospital-based practices today remain predominantly disease-oriented, focusing on individual clinical specialties with less visibility on a comprehensive picture of each patient's health needs. To tackle the challenge of growing multimorbidity worldwide, practices without disease-specific focus have shown better integration of services. However, as we move away from the familiar disease-specific approaches of care delivery, many of us are still learning how to implement generalist care in a cost-effective manner. METHODS This mixed-method case study, which centred on a specialist-led General Medicine model implemented at an acute hospital in Singapore, aimed to (1) quantitatively summarise its clinical outcomes, and (2) qualitatively describe the challenges and lessons gathered from the pragmatic implementation of the care model. Quantitative hospital data were extracted from databases and summarised. Qualitative staff-reported experiences and insights were gathered through semi-structured interviews and analysed using thematic analysis. RESULTS Quantitative findings revealed that the generalist care model was implemented with high fidelity, where more than 75% of patients admitted were placed under General Medicine's or General Surgery's care. The mean length of stay was 2.6 days, and the 30-day post-discharge readmission rate was 15%. Inpatient mortality rate was found to be 2.8%, and the average gross hospitalisation bill amounted to SGD3,085.30. For qualitative findings, themes concerning feasibility and operational aspects of the implementation were grouped into categories- (1) Feasibility of 'One Care Team' approach, (2) Enablers required for meaningful generalist care, (3) Challenges surrounding information sharing, (4) Lack of integration with the community to facilitate care transition, and (5) Evolving roles of self-management. The findings were rich, with some being identified as barriers that could benefit from system-level de-constraining. DISCUSSION This case study was an illustration of our pursuit for an integrated solution to rising prevalence of multimorbidity. While quantitative findings indicated that a pivot towards General Medicine might be possible, data also revealed gaps in clinical outcomes, especially in readmission rates. These findings corroborated with much of the lessons and challenges gathered from qualitative interviews, specifically surrounding the lack of receptacles in the community to facilitate care transition, training, and competency of generalists in holistic management of complex multimorbid cases, as well as inadequate infrastructure to allow information sharing between providers. Thus, a multi-pronged approach might be required to develop a new and sustainable care model for patients with multimorbidity in the long run. In the short to medium transitional period, nonetheless, the specialist-led General Medicine care model demonstrated might be a viable interim approach, especially in circumstances where trained medical generalists remained limited.
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Affiliation(s)
- Yi Feng Lai
- MOH Office for Healthcare Transformation, Ministry of Health, Singapore City, Singapore
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Department of Pharmacy, National University of Singapore, Singapore City, Singapore
| | - Sophia Yi-Fei Lee
- Business School, National University of Singapore, Singapore City, Singapore
| | - Jun Xiong
- Business School, National University of Singapore, Singapore City, Singapore
| | - Si Yun Leow
- Business School, National University of Singapore, Singapore City, Singapore
| | - Cher Wee Lim
- MOH Office for Healthcare Transformation, Ministry of Health, Singapore City, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore City, Singapore
| | - Biauw Chi Ong
- Medical Board, Sengkang General Hospital, Singapore City, Singapore
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18
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Foo CD, Tan YL, Shrestha P, Eh KX, Ang IYH, Nurjono M, Toh SA, Shiraz F. Exploring the dimensions of patient experience for community-based care programmes in a multi-ethnic Asian context. PLoS One 2020; 15:e0242610. [PMID: 33237953 PMCID: PMC7688169 DOI: 10.1371/journal.pone.0242610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/06/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction The aim of this study is to explore patients’ experiences with community-based care programmes (CCPs) and develop dimensions of patient experience salient to community-based care in Singapore. Most countries like Singapore are transforming its healthcare system from a hospital-centric model to a person-centered community-based care model to better manage the increasing chronic disease burden resulting from an ageing population. It is thus critical to understand the impact of hospital to community transitions from the patients’ perspective. The exploration of patient experience will guide the development of an instrument for the evaluation of CCPs for quality improvement purposes. Methods A qualitative exploratory study was conducted where face-to-face in-depth interviews were conducted using a purposive sampling method with patients enrolled in CCPs. In total, 64 participants aged between 41 to 94 years were recruited. A deductive framework was developed using the Picker Patient Experience instrument to guide our analysis. Inductive coding was also conducted which resulted in emergence of new themes. Results Our findings highlighted eight key themes of patient experience: i) ensuring care continuity, ii) involvement of family, iii) access to emotional support, vi) ensuring physical comfort, v) coordination of services between providers, vi) providing patient education, vii) importance of respect for patients, and viii) healthcare financing. Conclusion Our results demonstrated that patient experience is multi-faceted, and dimensions of patient experience vary according to healthcare settings. As most patient experience frameworks were developed based on a single care setting in western populations, our findings can inform the development of a culturally relevant instrument to measure patient experience of community-based care for a multi-ethnic Asian context.
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Affiliation(s)
- Chuan De Foo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- * E-mail:
| | - Yan Lin Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Pami Shrestha
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Singapore Population Health Improvement Centre (SPHERiC), National University Health System, Singapore, Singapore
| | - Ke Xin Eh
- Singapore Population Health Improvement Centre (SPHERiC), National University Health System, Singapore, Singapore
- Regional Health System Office, National University Health System, Singapore, Singapore
| | - Ian Yi Han Ang
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Regional Health System Office, National University Health System, Singapore, Singapore
| | - Milawaty Nurjono
- Centre for Health Services and Policy Research (CHSPR), Saw Swee Hock School of Public Health National University of Singapore, Singapore, Singapore
- Health Services Research, Changi General Hospital, Singapore Health Services, Singapore, Singapore
| | - Sue-Anne Toh
- Singapore Population Health Improvement Centre (SPHERiC), National University Health System, Singapore, Singapore
- Regional Health System Office, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Farah Shiraz
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Singapore Population Health Improvement Centre (SPHERiC), National University Health System, Singapore, Singapore
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Foo KM, Sundram M, Legido-Quigley H. Facilitators and barriers of managing patients with multiple chronic conditions in the community: a qualitative study. BMC Public Health 2020; 20:273. [PMID: 32106838 PMCID: PMC7045577 DOI: 10.1186/s12889-020-8375-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/19/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Approximately one-third of all adults worldwide are diagnosed with multiple chronic conditions (MCCs). The literature has identified several challenges facing providers and patients coping with managing MCCs in the community, yet few studies have considered their viewpoints in combination. A qualitative study involving healthcare providers and users was thus conducted to examine facilitators and barriers of managing patients with MCCs in the community in Singapore. METHODS This study involves 26 semi-structured interviews with 10 physicians, 2 caregivers and 14 patients seeking treatment in the polyclinics that provide subsidised primary care services. Topic guides were developed with reference to the literature review, Chronic Care Model (CCM) and framework for patient-centred access to healthcare. RESULTS Despite the perceived affordability and availability of the support system, some patients still encountered financial difficulties in managing care. These include inadequacy of the nation-wide medical savings scheme to cover outpatient treatment and medications. Half of healthcare users did not know where to seek help. While patients could access comprehensive services in polyclinics, those who did not visit the clinics might not receive timely care. Furthermore, patients reported long consultation waiting time. Physicians were able to propose and drive quality improvement projects to improve care quality. However, there were challenges to delivering safe and quality care with limited consultation duration due to the need to manage high patient load and waiting time, inadequate communication with specialists to coordinate care, and resource constraints in managing complex patients. Although providers could equip patients with self-management and lifestyle-related guidelines, patients' actions are influenced by multiple factors, including work requirements, beliefs and environment. CONCLUSIONS There were barriers on care access, delivery and self-management. It is crucial to adopt a whole-of-society approach involving individuals, community, institutions and policymakers to improve and support MCC management. This study has also highlighted the importance of considering the different viewpoints of healthcare providers and users in policy formulation and community care planning.
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Affiliation(s)
- Kah Mun Foo
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Tahir Foundation Building, Singapore, 117549, Singapore.
- National University Polyclinics, Singapore, 1 Jurong East Street 21, Singapore, 609606, Singapore.
| | - Meena Sundram
- National University Polyclinics, Singapore, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Tahir Foundation Building, Singapore, 117549, Singapore
- London School of Hygiene and Tropical Medicine, London, WC1H 9SH, UK
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The Mixed-Method 5W2D Approach for Health System Stakeholders Analysis in Quality of Care: An Application to the Moroccan Context. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16162899. [PMID: 31412655 PMCID: PMC6719162 DOI: 10.3390/ijerph16162899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/05/2019] [Accepted: 08/09/2019] [Indexed: 01/06/2023]
Abstract
(1) Background: Quality of care (QC) is not only about satisfying patients, but also about satisfying the various health system stakeholders (HSS). This makes it a complex and difficult objective to achieve. This study aims at proposing a methodological framework for identifying HSS, prioritizing them in QC, and analyzing their interrelationships. (2) Methods: The proposed framework is the mixed-method 5W2D approach, which uses a combination of three basic methods: the 5W questioning technique (What, Who, Why, Where, and When), the Delphi method, and the Decision making trial and evaluation laboratory (DEMATEL) technique. It consists of three interdependent phases. First of all, a preliminary list of HSS is established based on a systematic literature review, which is then projected and adapted to the national context using the 5W questioning technique. Secondly, the identified HSS are classified in order according to their influence and impact on QC by employing Delphi method. Thirdly, the interrelationships between HSS are determined and analyzed by applying DEMATEL technique. An application of 5W2D is conducted in the Moroccan context as its health system involves a wide range of stakeholders. (3) Results: Results defined 17 groups of HSS, whose prioritization led to three groups that are at the core of the health system: patients and their families, health personnel, and government. Roles and expectations of these groups regarding QC are divergent and contradictory, which require making trade-offs. The findings of this study intend to guide the development of inclusive strategies and policies that involve key stakeholders for QC assessment and improvement.
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Thumboo J, Yoon S, Wee S, Yeam CT, Low ECT, Lee CE. Developing population health research priorities in Asian city state: Results from a multi-step participatory community engagement. PLoS One 2019; 14:e0216303. [PMID: 31042782 PMCID: PMC6493761 DOI: 10.1371/journal.pone.0216303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/17/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To identify a broad range of research priorities to inform the studies seeking to improve population health outcomes based on the engagement of diverse stakeholders. METHODS A multi-step, participatory and mixed-methods approach was adopted to solicit and structure the investigative themes from diverse stakeholders. The priority setting exercise involved four key phases: (1) feedback from community leadership; (2) interim ranking survey and focus group discussions during the population health symposium; (3) individual in-depth interviews with stakeholders in the community; and (4) synthesis of the research priorities from the multistep process. RESULTS Diverse stakeholders in Singapore, comprising community partnership leaders, health care and social service providers, users of population health services, patients and caregivers, participated in the research priority setting exercise. Initial 14 priorities were identified from six community leadership feedback, 42 survey responses, two focus groups (n = 16) and 95 in-depth interviews. The final integrated research agenda identified six priorities: empower residents and patients to take charge of their health; improve care transition and management through relationship building and communication; enhance health-social care interface; improve respite care services for long-term caregivers; develop primary care as a driving force for care integration; and capacity building for service providers. Selected research questions in each priority area were also generated to develop novel models of care, foster collaboration, implement optimal services and enhance understanding of the end users' care needs. CONCLUSIONS This study illuminates that greater community engagement in research priority setting for population health can facilitate the formulation of evidence-based research agendas that matter to the care providers and service users in the community. The outcomes derived from this exercise will help focus researchers' efforts through which meaningful gains can be made for population health.
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Affiliation(s)
- Julian Thumboo
- Regional Health System, Singapore Health Services, Singapore, Singapore
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- * E-mail:
| | - Sungwon Yoon
- Regional Health System, Singapore Health Services, Singapore, Singapore
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Sharon Wee
- Regional Health System, Singapore Health Services, Singapore, Singapore
| | | | - Edwin C. T. Low
- Regional Health System, Singapore Health Services, Singapore, Singapore
| | - Chien Earn Lee
- Regional Health System, Singapore Health Services, Singapore, Singapore
- Changi General Hospital, Singapore, Singapore
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East Asia – A look at selected health policy developments and health care assessments in universal health coverage systems. Health Policy 2019; 123:343-344. [DOI: 10.1016/j.healthpol.2019.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Nurjono M, Shrestha P, Ang IYH, Shiraz F, Yoong JSY, Toh SAES, Vrijhoef HJM. Implementation fidelity of a strategy to integrate service delivery: learnings from a transitional care program for individuals with complex needs in Singapore. BMC Health Serv Res 2019; 19:177. [PMID: 30890134 PMCID: PMC6425607 DOI: 10.1186/s12913-019-3980-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 02/28/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) - RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs. METHODS Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases. RESULTS Most (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs' level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers. CONCLUSION This is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.
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Affiliation(s)
- Milawaty Nurjono
- Centre for Health Services Research and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Pami Shrestha
- Regional Health System Planning Office, National University Health System, Singapore, Singapore
| | - Ian Yi Han Ang
- Regional Health System Planning Office, National University Health System, Singapore, Singapore
| | - Farah Shiraz
- Regional Health System Planning Office, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Joanne Su-Yin Yoong
- Center for Economic and Social Research, University of Southern California, Los Angeles, USA
| | - Sue-Anne Ee Shiow Toh
- Regional Health System Planning Office, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Hubertus Johannes Maria Vrijhoef
- Department of Patient and Care, University Hospital Maastricht, Maastricht, The Netherlands
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussels, Brussels, Belgium
- Panaxea B.V, Amsterdam, The Netherlands
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Ow Yong LM, Cameron A. Learning from elsewhere: Integrated care development in Singapore. Health Policy 2018; 123:393-402. [PMID: 30579625 DOI: 10.1016/j.healthpol.2018.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 12/08/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022]
Abstract
The Singapore healthcare sector faces a myriad of challenges, including a rapidly ageing population, an increasing burden of chronic disease, and the rising cost of healthcare. The Ministry of Health has called for a restructuring and transformation of the current model of care to one that is more accessible, affordable and of higher quality, by the year 2020. In achieving quality health care, care integration through the Regional Health Systems (RHS) is seen as one approach to improving health and social outcomes, increasing healthcare utilisation and increasing satisfaction with healthcare providers. We conducted a qualitative study involving 31 elites from five policy agent clusters, and analysed organisational documents, to explore how the concepts of policy transfer and policy translation, explain the ways in which integrated care was introduced and developed in Singapore, with a focus on the SingHealth (SGH Campus) Regional Health System (RHS). The findings demonstrate that the development of integrated care is mediated by multi-scalar and multi-site networks and contextual features. The multiple and pluralistic interpretations of 'integrated care' and 'policy' are contested spaces or domains requiring further negotiation and debate. Institutional issues in the SingHealth (SGH Campus) RHS, and in the private and ILTC sectors highlight the need to consider spatial and temporal factors, and the multiplexities in the embedding of integrated care policy.
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Affiliation(s)
- Lai Meng Ow Yong
- Centre for Research in Health and Social Care, School for Policy Studies, University of Bristol, UK; Medical Social Services, Singapore General Hospital, Singapore.
| | - Ailsa Cameron
- Centre for Research in Health and Social Care, School for Policy Studies, University of Bristol, UK.
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Abstract
Background: Integrated care that focuses on organising healthcare services around people and their communities rather than their diseases is promoted as the strategy to overcome the challenges associated with growing complexity in healthcare needs, demand for healthcare services and inadequate supply of services due to fragmentation in the provision of services. While conceptually appears to be simple, integrated care is made up of multicomponent delivery strategies targeting various levels of the healthcare system while engaging various stakeholders in their execution. Methods: We applied the complex adaptive system (CAS) perspective to two different initiatives that exemplify approaches towards integrating care in Singapore: the Regional Health System (RHS) model, implemented across healthcare institutions at the national level, and CARITAS Integrated Dementia Care implemented in the northern region of Singapore. We adopted an inductive approach in our analysis in which we studied the RHS and CARITAS Integrated Dementia Care according to the components of the CAS. We applied the typical characteristics of CAS: (i) diverse, interdependent and semi-autonomous actors (ii) self-organizing capacity and simple rules (iii) relationship with the bigger system, emergent behaviour and non-linearity in our analysis of key drivers behind the implementation of both the RHS and CARITAS integrated dementia care. Results: By considering the RHS and CARITAS as whole networks each comprising of interacting and adaptive components instead of separate entities within a bigger system, the CAS provided a new mind-set in surfacing issues associated to the implementation of these integrated care networks. In addition to important actors, systems, it informed understanding of relationships and dependencies between different parts of the network – revealing the lack of homogeneity, conformity and difficulties in designing any optimal system in advance given the many moving parts. Conclusions: Drawing on the two examples of integrated care networks, this paper highlights the significance of effective collaboration built on a common focus, responsiveness to emergent behaviours, simple rules, the ability to self-organize and adapt in response to unexpected situations in further development of integrated care in the Singapore context and beyond.
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