Frequent hospital admissions in Singapore: clinical risk factors and impact of socioeconomic status

Is alcohol and psychoactive medication use associated with excess hospital length-of-stay and admission frequency? A cross-sectional, observational study

BACKGROUND

Hospital length-of-stay and admission frequency are commonly used indicators of disease burden and health resource expenditures. However, the impact of psychoactive prescription medication use and harmful alcohol consumption on both the duration and frequency of hospital admissions is under-explored.

METHODS

We conducted an analysis of data gathered from 2872 patients admitted to the Emergency Department at Lovisenberg Diaconal Hospital in Oslo, Norway. Psychoactive medicines (benzodiazepines, opioids, and z-hypnotics) were detected via liquid chromatography-mass spectrometry analysis of whole blood, while alcohol consumption was self-reported through the Alcohol Use Disorder Identification Test-4 (AUDIT-4). Using logistic regression, we examined associations with our primary outcomes, which were excess length-of-stay and admission frequency, defined as exceeding the sample median of 3.0 days and 0.2 admissions per year, respectively.

RESULTS

Compared to the absence of psychoactive medication, and after adjusting for age, gender, malignant disease, pre-existing substance use disorder and admission due to intoxication, the detection of two or more psychoactive medicines was associated with both excess length-of-stay (odds ratio [OR], 1.60; 95% confidence interval [CI], 1.20 to 2.14) and yearly hospitalization rate (OR, 3.72; 95% CI, 2.64 to 5.23). This association persisted when increasing the definition for excess length-of-stay to 4 and 5 days and to 1.0 and 1.5 admissions per year for admission frequency. Harmful alcohol consumption (AUDIT-4 scores of 9 to 16) was not associated with excess length-of-stay, but with excess admission frequency when defined as more than 1.0 admission per year when compared to scores of 4 to 6 (OR, 2.68; 95% CI, 1.58 to 4.57).

CONCLUSIONS

Psychoactive medication use is associated with both excess length-of-stay and increased antecedent admission frequency, while harmful alcohol consumption may be associated with the latter. The utility of our findings as a causal factor should be explored through intervention-based study designs.

Patients with repeated acute admissions to somatic departments: sociodemographic characteristics, disease burden, and contact with primary healthcare sector - a retrospective register-based case-control study

BACKGROUND

Healthcare systems face escalating capacity challenges and patients with repeated acute admissions strain hospital resources disproportionately. However, studies investigating the characteristics of such patients across all public healthcare providers in a universal healthcare system are lacking.

OBJECTIVE

To investigate characteristics of patients with repeated acute admissions (three or more acute admissions within a calendar year) in regard to sociodemographic characteristics, disease burden, and contact with the primary healthcare sector.

METHODS

This matched register-based case-control study investigated repeated acute admissions from 1 January 2014 to 31 December 2018, among individuals, who resided in four Danish municipalities. The study included 6169 individuals with repeated acute admissions, matched 1:4 to individuals with no acute admissions and one to two acute admissions, respectively. Group comparisons were conducted using conditional logistic regression.

RESULTS

Receiving social benefits increased the odds of repeated acute admissions 9.5-fold compared with no acute admissions (odds ratio (OR) 9.5; 95% confidence interval (CI) 8.5; 10.6) and 3.4-fold compared with one to two acute admissions (OR 3.4; 95% CI 3.1; 3.7). The odds of repeated acute admissions increased with the number of used medications and chronic diseases. Having a mental illness increased the odds of repeated acute admissions 5.8-fold when compared with no acute admissions (OR 5.7; 95% CI 5.2; 6.4) and 2.3-fold compared with one to two acute admissions (OR 2.3; 95% CI 2.1; 2.5). Also, high use of primary sector services (e.g. nursing care) increased the odds of repeated acute admissions when compared with no acute admissions and one to two acute admissions.

CONCLUSIONS

This study pinpointed key factors encompassing social status, disease burden, and healthcare utilisation as pivotal markers of risk for repeated acute admissions, thus identifying high-risk patients and facilitating targeted intervention.

Predictors of frequency of 1-year readmission in adult patients with diabetes

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.

The cost-effectiveness of a real-time seizure detection application for people with epilepsy

OBJECTIVES

Automated seizure detection modalities can increase safety among people with epilepsy (PWE) and reduce seizure-related anxiety. We evaluated the potential cost-effectiveness of a seizure detection mobile application for PWE in Singapore.

METHODS

We used a Markov cohort model to estimate the expected changes to total costs and health outcomes from a decision to adopt the seizure detection application versus the current standard of care from the health provider perspective. The time horizon is ten years and cycle duration is one month. Parameter values were updated from national databases and published literature. As we do not know the application efficacy in reducing seizure-related injuries, a conservative estimate of 1% reduction was used. Probabilistic sensitivity analysis, scenario analyses, and value of information analysis were performed.

RESULTS

At a willingness-to-pay of $45,000/ quality-adjusted life-years (QALY), the incremental cost-effectiveness ratio was $1,096/QALY, and the incremental net monetary benefit was $13,656. Probabilistic sensitivity analyses reported that the application had a 99.5% chance of being cost-effective. In a scenario analysis in which the reduction in risk of seizure-related injury was 20%, there was a 99.8% chance that the application was cost-effective. Value of information analysis revealed that health utilities was the most important parameter group contributing to model uncertainty.

CONCLUSIONS

This early-stage modeling study reveals that the seizure detection application is likely to be cost-effective compared to current standard of care. Future prospective trials will be needed to demonstrate the real-world impact of the application. Changes in health-related quality of life should also be measured in future trials.

Predictors of unplanned hospital readmission after non-cardiac surgery in Singapore: a 2-year retrospective review

INTRODUCTION

Unplanned hospital readmissions after surgery contribute significantly to healthcare costs and potential complications. Identifying predictors of readmission is inherently complex and involves an intricate interplay between medical factors, healthcare system factors and sociocultural factors. Therefore, the aim of this study was to elucidate the predictors of readmissions in an Asian surgical patient population.

METHODS

A two-year single-institution retrospective cohort study of 2744 patients was performed in a university-affiliated tertiary hospital in Singapore, including patients aged 45 and above undergoing intermediate or high-risk non-cardiac surgery. Unadjusted analysis was first performed, followed by multivariable logistic regression.

RESULTS

Two hundred forty-nine patients (9.1%) had unplanned 30-day readmissions. Significant predictors identified from multivariable analysis include: American Society of Anaesthesiologists (ASA) Classification grades 3 to 5 (adjusted OR 1.51, 95% CI 1.10-2.08, p = 0.01), obesity (adjusted OR 1.66, 95% CI 1.18-2.34, p = 0.04), asthma (OR 1.70, 95% CI 1.03-2.81, p = 0.04), renal disease (OR 2.03, 95% CI 1.41-2.92, p < 0.001), malignancy (OR 1.68, 95% CI 1.29-2.37, p < 0.001), chronic obstructive pulmonary disease (OR 2.46, 95% CI 1.19-5.11, p = 0.02), cerebrovascular disease (OR 1.73, 95% CI 1.17-2.58, p < 0.001) and anaemia (OR 1.45, 95% CI 1.07-1.96, p = 0.02).

CONCLUSION

Several significant predictors of unplanned readmissions identified in this Asian surgical population corroborate well with findings from Western studies. Further research will require future prospective studies and development of predictive risk modelling to further address and mitigate this phenomenon.

Impact of a Bedside Activity Device on the Functional Status of Hospitalized Older Adults: A Randomized Controlled Trial

BACKGROUND

Older adults may have difficulty maintaining their functional capabilities during hospitalization. This pilot study aimed to investigate the impact of a bedside activity device on the functional status of hospitalized older adults.

METHODS

For this single-site randomized controlled trial, 48 participants were recruited between July 2019 and March 2021. Participants were randomized into one of two groups: the intervention group, which was given the use of a bedside activity device plus standard care, and the control group, which received standard care. Katz Index of Independence in Activities of Daily Living (Katz ADL) scores and Timed Up and Go (TUG) test times were used as indicators of functional status and were collected on admission (baseline) and at discharge.Mann-Whitney U and χ 2 tests were used to test for baseline similarities between groups. The Wilcoxon signed rank test was used to determine within-group pre-post changes in TUG and Katz ADL scores. The Mann-Whitney U test was used to determine between-group differences in TUG and Katz ADL change scores.

RESULTS

Within-group pre-post analysis showed significant increases in Katz ADL scores in the intervention group and no significant changes in the control group. TUG times decreased significantly in the intervention group and increased significantly in the control group. Between-group analyses showed significant differences in both TUG and Katz ADL change scores.

CONCLUSION

The use of the bedside activity device in addition to standard care may prevent functional decline and increase independence in performing basic ADLs.

A prospective cohort study assessing aggressive interventions at the end-of-life among patients with solid metastatic cancer

Background

Many patients with a solid metastatic cancer are treated aggressively during their last month of life. Using data from a large prospective cohort study of patients with an advanced cancer, we aimed to assess the number and predictors of aggressive interventions during last month of life among patients with solid metastatic cancer and its association with bereaved caregivers’ outcomes.

Methods

We used data of 345 deceased patients from a prospective cohort study of 600 patients. We surveyed patients every 3 months until death for their physical, psychological and functional health, end-of-life care preference and palliative care use. We surveyed their bereaved caregivers 8 weeks after patients’ death regarding their preparedness about patient’s death, regret about patient’s end-of-life care and mood over the last week. Patient data was merged with medical records to assess aggressive interventions received including hospital death and use of anti-cancer treatment, more than 14 days in hospital, more than one hospital admission, more than one emergency room visit and at least one intensive care unit admission, all within the last month of life.

Results

69% of patients received at least one aggressive intervention during last month of life. Patients hospitalized during the last 2–12 months of life, male patients, Buddhist or Taoist, and with breast or respiratory cancer received more aggressive interventions in last month of life. Patients with worse functional health prior to their last month of life received fewer aggressive interventions in last month of life. Bereaved caregivers of patients receiving more aggressive interventions reported feeling less prepared for patients’ death.

Conclusion

Findings suggest that intervening early in the sub-group of patients with history of hospitalization prior to their last month may reduce number of aggressive interventions during last month of life and ultimately positively influence caregivers’ preparedness for death during the bereavement phase.

Trial registration

NCT02850640.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00970-z.

Community nurses' perspectives on a novel blended training approach: a qualitative study

Background

Transiting into the community setting often presents novel difficulties for nurses because the role demands skills that might not have been obtained through usual clinical experience or training. The Ageing-in-Place Community Care Team (AIP-CCT) Community Nurse Basic Training programme was developed to address this learning gap. This training programme prepares nurses to lead in a multi-disciplinary team in delivering patient-centred care to patients with progressive or life-limiting conditions in the community setting. This study evaluated the inaugural training programme provided to a group of nurses from an acute hospital in Singapore.

Methods

Qualitative in-depth interviews were carried out with 13 participants from the training programme three-months after completion of the AIP-CCT Community Nurse Basic Training programme provided by an acute hospital to understand the programme’s impact on their knowledge, skills and clinical practice, as well as barriers and facilitators to learning.

Results

Overall, perception towards the training course was mixed. Course content was found to be relevant, and participants reported that training led to improvement in their practice. However, experienced nurses felt that the content of some modules were lacking in depth. This could have explained why only junior nurses tended to hold favourable attitudes and felt that the training led to increase in their confidence level. Although medical content was assessed favourably, the course was not able to address some of the constraints faced by community nurses such as managing expectations and handling difficult patients in the home care setting. For some modules, face-to-face training was preferred and e-learning components can be improved to increase communication and interaction.

Conclusion

This study provided insights into how a community nurse training programme could be developed to meet the needs of community nurses. The training was able to reinforce skills and knowledge, address knowledge gaps and provide new clinical care approaches and communication strategies. These incremental effects on experienced community nurses could be extrapolated to have greater benefits for inexperienced community nurses. Based on findings of the study, potential changes to the training programme were discussed to improve training outcomes.

Identifying high-risk hospitalised chronic kidney disease patient using electronic health records for serious illness conversation

INTRODUCTION

This study aimed to identify risk factors that are associated with increased mortality that could prompt a serious illness conversation (SIC) among patients with chronic kidney disease (CKD).

METHODS

The electronic health records of adult CKD patients admitted between August 2018 and February 2020 were retrospectively reviewed to identify CKD patients with >1 hospitalisation and length of hospital stay ≥4 days. Outcome measures were mortality and the duration of hospitalisation. We also assessed the utility of the Cohen's model to predict 6-month mortality among CKD patients.

RESULTS

A total of 442 patients (mean age 68.6 years) with median follow-up of 15.3 months were identified. The mean (standard deviation) Charlson Comorbidity Index [CCI] was 6.8±2.0 with 48.4% on chronic dialysis. The overall mortality rate until August 2020 was 36.7%. Mortality was associated with age (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.29-1.77), CCI≥7 (1.58, 1.08-2.30), lower serum albumin (1.09, 1.06-1.11), readmission within 30-day (1.96, 1.43-2.68) and CKD non-dialysis (1.52, 1.04-2.17). Subgroup analysis of the patients within first 6-month from index admission revealed longer hospitalisation stay for those who died (CKD-non dialysis: 5.5; CKD-dialysis: 8.0 versus 4 days for those survived, P<0.001). The Cohen's model demonstrated reasonable predictive ability to discriminate 6-month mortality (area under the curve 0.81, 95% CI 0.75-0.87). Only 24 (5.4%) CKD patients completed advanced care planning.

CONCLUSION

CCI, serum albumin and recent hospital readmission could identify CKD patients at higher risk of mortality who could benefit from a serious illness conversation.

Determinants of emergency department utilisation by older adults in Singapore: A systematic review

INTRODUCTION

Adults aged ≥60 years contribute to disproportionately higher visits to the emergency departments (ED). We performed a systematic review to examine the reasons why older persons visit the ED in Singapore.

METHODS

We searched Medline, Embase and Scopus from January 2000 to December 2021 for studies reporting on ED utilisation by older adults in Singapore, and included studies that investigated determinants of ED utilisation. Statistically significant determinants and their effect sizes were extracted. Determinants of ED utilisation were organised using Andersen and Newman's model. Quality of studies was evaluated using Newcastle Ottawa Scale and Critical Appraisal Skills Programme.

RESULTS

The search yielded 138 articles, of which 7 were used for analysis. Among the significant individual determinants were predisposing (staying in public rental housing, religiosity, loneliness, poorer coping), enabling (caregiver distress from behavioural and psychological symptoms of dementia) and health factors (multimorbidity in patients with dementia, frailty, primary care visit in last 6 months, better treatment adherence). The 7 included studies are of moderate quality and none of them employed conceptual frameworks to organise determinants of ED utilisation.

CONCLUSION

The major determinants of ED utilisation by older adults in Singapore were largely individual factors. Evaluation of societal determinants of ED utilisation was lacking in the included studies. There is a need for a more holistic examination of determinants of ED utilisation locally based on conceptual models of health seeking behaviours.

Effect of a Real-Time Risk Score on 30-day Readmission Reduction in Singapore

OBJECTIVE

To develop a risk score for the real-time prediction of readmissions for patients using patient specific information captured in electronic medical records (EMR) in Singapore to enable the prospective identification of high-risk patients for enrolment in timely interventions.

METHODS

Machine-learning models were built to estimate the probability of a patient being readmitted within 30 days of discharge. EMR of 25,472 patients discharged from the medicine department at Ng Teng Fong General Hospital between January 2016 and December 2016 were extracted retrospectively for training and internal validation of the models. We developed and implemented a real-time 30-day readmission risk score generation in the EMR system, which enabled the flagging of high-risk patients to care providers in the hospital. Based on the daily high-risk patient list, the various interfaces and flow sheets in the EMR were configured according to the information needs of the various stakeholders such as the inpatient medical, nursing, case management, emergency department, and postdischarge care teams.

RESULTS

Overall, the machine-learning models achieved good performance with area under the receiver operating characteristic ranging from 0.77 to 0.81. The models were used to proactively identify and attend to patients who are at risk of readmission before an actual readmission occurs. This approach successfully reduced the 30-day readmission rate for patients admitted to the medicine department from 11.7% in 2017 to 10.1% in 2019 (p < 0.01) after risk adjustment.

CONCLUSION

Machine-learning models can be deployed in the EMR system to provide real-time forecasts for a more comprehensive outlook in the aspects of decision-making and care provision.

The impact of common variables on non-attendance at a radiology centre in Singapore

INTRODUCTION

With the increasing demand for medical imaging, non-attendance inhibits private and public radiology practices in Singapore from providing timely care and achieving maximal efficiency. Missed radiological appointments adversely affect clinical and economic outcomes and strain the finite healthcare resources. We examined the prevalence and predictors of patient non-attendance for radiological services at a regional public hospital in Singapore and compared them against other medical imaging centres globally.

METHODS

Outpatient records of patients who were scheduled for specialised medical imaging obtained from Radiological Information System (RIS) were retrospectively reviewed. Analysed variables include patient demographics, radiology modalities, visit statuses and appointment lead times where Pearson's chi-square test and Fisher's exact test were used for categorical variables, and independent sample t-test was used for continuous variables. The association between each patient characteristic and non-attendance status was assessed using Binary Logistics Regression. Variables that showed statistical significance in univariate analysis were included in the multivariate logistic regression model to identify the independent risk factors associated with non-attendance.

RESULTS

Among the 59,748 outpatient appointments with medical imaging requests, 15.5% did not turn up for their appointments. Logistic regression indicated that patient's age, ethnicity, subsidy status, house ownership, living vicinity to regional hospital cluster, appointment wait times, appointment hours and appointment months were significant factors associated with the failure to attend scheduled radiological examinations.

CONCLUSION

Even though predictors of non-attendance remained consistent across medical imaging centres worldwide, Singapore reported a higher prevalence of missed appointments calling for future exploratory studies to understand the population's health-seeking behaviours and ordering patterns of clinicians.

IMPLICATIONS FOR PRACTICE

Comparison and identification of these predictors will assist in the design of targeted interventions that may improve patient's adherence and utilisation of imaging services.

Frailty and healthcare utilisation across care settings among community-dwelling older adults in Singapore

Background

Frailty is frequently found to be associated with increased healthcare utilisation in western countries, but little is known in Asian population. This study was conducted to investigate the association between frailty and healthcare utilisation in different care settings among community-dwelling older adults in Singapore.

Methods

Data from a population health survey among community-dwelling adults were linked with an administrative database to retrieve data of healthcare utilisation (including government primary care clinic visits, specialised outpatient clinic visits, emergency department visits, day surgery and hospitalisations) occurred during a six-month look-back period and six-month post-baseline respectively. Baseline frailty status was measured using the five-item FRAIL scale, which was categorised into three groups: robust (0), pre-frail (1–2), and frail (3–5). Negative binomial regression was applied to examine the association between frailty with respective healthcare utilisation (dependent variables), controlling for other confounding variables.

Results

In our sample of 701 older adults, 64.8% were of robust health, 27.7% were pre-frail, and 7.6% were frail. Compared to the robust group, frail individuals had a higher rate of specialised outpatient clinic visits (incidence rate ratio (IRR): 2.8, 95% confidence interval (CI): 1.2–6.5), emergency department visits (IRR: 3.1, 95%CI: 1.1–8.1), day surgery attendances (IRR: 6.4, 95%CI: 1.3–30.9), and hospitalisations (IRR: 6.7, 95%CI: 2.1–21.1) in the six-month period prior to the baseline and in subsequent 6 months (IRR: 3.3, 95%CI: 1.6–7.1; 6.4, 2.4–17.2; 5.8, 1.3–25.8; 13.1, 4.9–35.0; respectively), controlling for covariates.

Conclusions

Frailty was positively associated with the number of specialised outpatient clinic visits, emergency department visits, day surgeries and hospitalisations occurred during 6 months prior to and after the baseline. As frailty is a potentially reversible health state with early screening and intervention, providing preventive activities that delay the onset or progression of frailty should have potential effect on delaying secondary and tertiary care utilisation.

Incidence of chronic wounds in Singapore, a multiethnic Asian country, between 2000 and 2017: a retrospective cohort study using a nationwide claims database

OBJECTIVES

Chronic wounds are common, costly and impair quality of life, yet epidemiological data are scarce. We aimed to estimate the incidence trend of a multiethnic Asian population.

DESIGN

Retrospective cohort study.

SETTING

Singapore's nationwide claims database.

PARTICIPANTS

Singaporeans and permanent residents.

OUTCOMES

Patients were identified by International Classification of Disease, Ninth Revision, Australian Modification (ICD-9-AM) and ICD-10-AM codes from all admissions between 2000 and 2017, and categorised according to aetiology: venous, arterial, diabetic and pressure. Comorbidities were extracted from a national database of Charlson Comorbidity Index scores.

RESULTS

Between 2000 and 2017, 124 023 wound-related claims among 86 631 patients were identified. Age-specific rate (ASR) and age-adjusted incidence rates of all wounds increased over 18 years, with greatest increases among those aged ≥80. In 2017, the median age of patients was 74 (IQR 63-84). Half were male (51%). 70% were ethnic Chinese, 15% Malay and 9% Indian. In 2017, the crude incidence rate (CIR) was 15 per 100 000 persons (95% CI 14 to 16) for venous wounds, 56 (95% CI 53 to 58) for arterial, 168 (95% CI 164 to 173) for diabetic and 183 (95% CI 179 to 188) for pressure wounds. The CIR of any chronic wound was 296 (95% CI 291 to 301). ASRs were greatest in patients aged ≥80: 92 (95% CI 74 to 112) for venous, 478 (95% CI 436 to 522) for arterial, 1791 (95% CI 1710 to 1876) for diabetic, 3647 (95% CI 3530 to 3766) for pressure and 4277 (95% CI 4151 to 4407) for any wound. Compared with the Chinese, Indians had thrice the ASRs of venous and arterial wounds and double the ASR of diabetic wounds. Malays had double the ASRs of arterial and diabetic wounds.

CONCLUSIONS

Chronic wounds are common in the elderly with significant ethnic disparities in this Asian cohort. With the incidence expected to rise with ageing populations, it is crucial to address health disparities and evaluate utilisation and cost to inform clinical practice and health policy.

Risk factors for unplanned hospital readmissions within 30 days of discharge among medical oncology patients: A retrospective medical record review

PURPOSE

This study aimed to identify the risk factors for unplanned hospital readmissions (UHR) within 30 days of discharge among medical oncology patients at a tertiary hospital in Singapore.

METHODS

This study is a retrospective, case-control medical record review of patients admitted to a medical oncology unit at a tertiary hospital between 1 June and October 31, 2017. During the study period, there were 1559 adult patients discharged alive from the medical oncology unit. Of this, 359 patients had experienced at least a 30-day UHR (cases). The cases were matched to those without a 30-day UHR (controls) by their primary reason for index admission and discharge date. After matching, 312 medical records (cases: 156; controls: 156) were analysed.

RESULTS

Of the 156 cases with a 30-day UHR, 46.2% (n = 72) were readmitted within the first 10 days of discharge. The top reasons contributing to the UHR were non-neutropenic infection (n = 41) and pain (n = 23). Multivariate analyses identified three independent risk factors that were associated with the 30-day UHR: (1) single marital status, (2) emergency department visit(s) in the past six months, and (3) recent decline in activities of daily living.

CONCLUSION

The study results can guide risk stratification to identify medical oncology patients at high risk for 30-day UHR. In addition, the results warrant the need to refine the inpatient assessments and discharge planning, as well as ensure the accurate referral to and allocation of community and outpatient resources so as to reduce the risk of UHR.

Pressure injuries among admissions to a hospital in the tropics

We report incidence rates for pressure injuries seen in an acute hospital in Singapore that were classified as Stage 3 or Stage 4. The characteristics of patients and the factors that explain variation in the primary outcome of duration of hospital stay are summarized. Existing data were available from Singapore General Hospital for all admissions from January 2016 to December 2019. Univariable analysis was done and a multivariable Poisson regression model estimated. Incidence rates declined from 4.05 to 3.4 per 1000 admissions in the 48 months between 2016 and 2019. The vast majority were community acquired with 75% in admission from the patients' home. Factors that explain variation in length of stay were, ethnicity; site of injury; community versus healthcare associated; inter-hospital transfer; fracture as reason for admission; and the number of days between admission and assessment of wound by specialist nurse. Stage 3 and 4 injuries arise in a home environment most often and are subsequently managed in acute hospital at high cost. These are novel epidemiological data from a hospital in the tropics where the potential to improve outcomes, implement screening and prevention, and thus increase the performance of health services is strong.

Health-seeking behaviour of the elderly living alone in an urbanised low-income community in Singapore

INTRODUCTION

Elderly persons who live alone are more likely to be socially isolated and at increased risk of adverse health outcomes, unnecessary hospital re-admissions and premature mortality. We aimed to understand the health-seeking behaviour of elderly persons living alone in public rental housing in Singapore.

METHODS

In-depth interviews were conducted using a semi-structured question guide. Participants were selected using a purposive sampling approach. Interviews were conducted until theme saturation was reached. Qualitative data collected was analysed using manual thematic coding methods.

RESULTS

Data analysis revealed five major themes: accessibility of healthcare services and financial assistance schemes; perceived high cost of care; self-management; self-reliance; and mismatch between perceived needs and services.

CONCLUSION

Elderly persons living in one-room rental flats are a resilient and resourceful group that values self-reliance and independence. Most of the elderly who live alone develop self-coping mechanisms to meet their healthcare needs rather than seek formal medical consultation. The insightful findings from this study should be taken into consideration when models of healthcare delivery are being reviewed and designed so as to support the disadvantaged elderly living alone.

Drivers of hospital expenditure and length of stay in an academic medical centre: a retrospective cross-sectional study

BACKGROUND

As healthcare expenditure and utilization continue to rise, understanding key drivers of hospital expenditure and utilization is crucial in policy development and service planning. This study aims to investigate micro drivers of hospital expenditure and length of stay (LOS) in an Academic Medical Centre.

METHODS

Data corresponding to 285,767 patients and 207,426 inpatient visits was extracted from electronic medical records of the National University of Hospital in Singapore between 2005 to 2013. Generalized linear models and generalized estimating equations were employed to build patient and inpatient visit models respectively. The patient models provide insight on the factors affecting overall expenditure and LOS, whereas the inpatient visit models provide insight on how expenditure and LOS accumulate longitudinally.

RESULTS

Although adjusted expenditure and LOS per inpatient visit were largely similar across socio-economic status (SES) groups, patients of lower SES groups accumulated greater expenditure and LOS over time due to more frequent visits. Admission to a ward class with greater government subsidies was associated with higher expenditure and LOS per inpatient visit. Inpatient death was also associated with higher expenditure per inpatient visit. Conditions that drove patient expenditure and LOS were largely similar, with mental illnesses affecting LOS to a larger extent. These observations on condition drivers largely held true at visit-level.

CONCLUSIONS

The findings highlight the importance of distinguishing the drivers of patient expenditure and inpatient utilization at the patient-level from those at the visit-level. This allows better understanding of the drivers of healthcare utilization and how utilization accumulates longitudinally, important for health policy and service planning.

Predictive ability of an expert-defined population segmentation framework for healthcare utilization and mortality - a retrospective cohort study

Background

Population segmentation of patients into parsimonious and relatively homogenous subgroups or segments based on healthcare requirements can aid healthcare resource planning and the development of targeted intervention programs. In this study, we evaluated the predictive ability of a previously described expert-defined segmentation approach on 3-year hospital utilization and mortality.

Methods

We segmented all adult patients who had a healthcare encounter with Singapore Health Services (SingHealth) in 2012 using the SingHealth Electronic Health Records (SingHealth EHRs). Patients were divided into non-overlapping segments defined as Mostly Healthy, Stable Chronic, Serious Acute, Complex Chronic without Frequent Hospital Admissions, Complex Chronic with Frequent Hospital Admissions, and End of Life, using a previously described expert-defined segmentation approach. Hospital admissions, emergency department attendances (ED), specialist outpatient clinic attendances (SOC) and mortality in different patient subgroups were analyzed from 2013 to 2015.

Results

819,993 patients were included in this study. Patients in Complex Chronic with Frequent Hospital Admissions segment were most likely to have a hospital admission (IRR 22.7; p < 0.001) and ED visit (IRR 14.5; p < 0.001) in the follow-on 3 years compared to other segments. Patients in the End of Life and Complex Chronic with Frequent Hospital Admissions segments had the lowest three-year survival rates of 58.2 and 62.6% respectively whereas other segments had survival rates of above 90% after 3 years.

Conclusion

In this study, we demonstrated the predictive ability of an expert-driven segmentation framework on longitudinal healthcare utilization and mortality.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4251-6) contains supplementary material, which is available to authorized users.

What do caregivers value and is there agreement in perception of met needs between nurses and caregivers?

INTRODUCTION

There is an increasing reliance on informal caregivers to continue the care of patients after discharge. This is a huge responsibility for caregivers and some may feel unprepared for the role. Without adequate support and understanding regarding their needs, patient care may be impeded. This study aimed to identify the needs valued by caregivers and if there was agreement between acute care nurses and caregivers in the perception of whether caregiver needs were being met.

METHODS

We conducted face-to-face interviews with 100 pairs of acute care nurses and caregivers. Participants were recruited from inpatient wards through convenience sampling. Questionnaires included demographic data of nurses and caregivers, patients' activities of daily living, and perception of caregiver needs being met in six domains of care. Independent t-test was used to compare mean values in each domain, and intraclass correlation coefficient was used to compare agreement in perception.

RESULTS

Caregivers valued reassurance the most. Three domains of care needs showed significant differences in perception of caregiver needs being met:reassurance (p = 0.002), honesty and timeliness (p = 0.008), and kindness and genuine care (p = 0.026). There was poor agreement in all six domains of caregiver needs being met between nurses and caregivers.

CONCLUSION

Although caregivers valued reassurance the most, there was poor agreement between acute care nurses and caregivers in the perception of caregiver needs being met. Hence, more attention should be paid to the caregiver's needs. Further studies can examine reasons for unmet caregiver needs and interventions to improve support for them.

Outpatient primary and tertiary healthcare utilisation among public rental housing residents in Singapore

Background

Globally, public housing is utilized to provide affordable housing for low-income households. Studies have shown an association between public housing and negative health outcomes. There is paucity of data pertaining to outpatient primary and tertiary healthcare resources utilization among public rental housing residents in Singapore.

Methods

A retrospective cohort study was performed, involving patients under the care of SingHealth Regional Health System (SHRS) in Year 2012. Healthcare utilization outcomes evaluated included number of outpatient primary and specialist care clinic visits, emergency department visits and hospitalization in Year 2011. Multivariate logistical analyses were used to examine the association between public rental housing and healthcare utilization.

Results

Of 147,105 patients, 10,400 (7.1%) patients stayed in public rental housing. There were more elderly (54.8 ± 18.0 vs 49.8 ± 17.1, p < 0.001) and male patients [5279 (50.8%) vs 56,892 (41.6%), p < 0.001] residing in public rental housing. Co-morbidities such as hypertension and hyperlipidemia were more prevalent among public rental housing patients. (p < 0.05).

After adjustment for covariates, public rental housing was not associated with frequent outpatient primary care clinic or specialist outpatient clinic attendances (p > 0.05). However, it was associated with increased number of emergency department visits (OR: 2.41, 95% CI: 2.12–2.74) and frequent hospitalization (OR: 1.56, 95% CI: 1.33–1.83).

Conclusion

Residing in public rental housing was not associated with increased utilization of outpatient healthcare resources despite patients’ higher disease burden and frequency of emergency department visits and hospitalizations. Further research is required to elucidate their health seeking behaviours.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4047-8) contains supplementary material, which is available to authorized users.

Processing of Electronic Medical Records for Health Services Research in an Academic Medical Center: Methods and Validation

Background

Electronic medical records (EMRs) contain a wealth of information that can support data-driven decision making in health care policy design and service planning. Although research using EMRs has become increasingly prevalent, challenges such as coding inconsistency, data validity, and lack of suitable measures in important domains still hinder the progress.

Objective

The objective of this study was to design a structured way to process records in administrative EMR systems for health services research and assess validity in selected areas.

Methods

On the basis of a local hospital EMR system in Singapore, we developed a structured framework for EMR data processing, including standardization and phenotyping of diagnosis codes, construction of cohort with multilevel views, and generation of variables and proxy measures to supplement primary data. Disease complexity was estimated by Charlson Comorbidity Index (CCI) and Polypharmacy Score (PPS), whereas socioeconomic status (SES) was estimated by housing type. Validity of modified diagnosis codes and derived measures were investigated.

Results

Visit-level (N=7,778,761) and patient-level records (n=549,109) were generated. The International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) codes were standardized to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) with a mapping rate of 87.1%. In all, 97.4% of the ICD-9-CM codes were phenotyped successfully using Clinical Classification Software by Agency for Healthcare Research and Quality. Diagnosis codes that underwent modification (truncation or zero addition) in standardization and phenotyping procedures had the modification validated by physicians, with validity rates of more than 90%. Disease complexity measures (CCI and PPS) and SES were found to be valid and robust after a correlation analysis and a multivariate regression analysis. CCI and PPS were correlated with each other and positively correlated with health care utilization measures. Larger housing type was associated with lower government subsidies received, suggesting association with higher SES. Profile of constructed cohorts showed differences in disease prevalence, disease complexity, and health care utilization in those aged above 65 years and those aged 65 years or younger.

Conclusions

The framework proposed in this study would be useful for other researchers working with EMR data for health services research. Further analyses would be needed to better understand differences observed in the cohorts.

Public rental housing and its association with mortality - a retrospective, cohort study

BACKGROUND

Socioeconomic status (SES) is a well-established determinant of health status and home ownership is a commonly used composite indicator of SES. Patients in low-income households often stay in public rental housing. The association between public rental housing and mortality has not been examined in Singapore.

METHODS

A retrospective, cohort study was conducted involving all patients who utilized the healthcare facilities under SingHealth Regional Health (SHRS) Services in Year 2012. Each patient was followed up for 5 years. Patients who were non-citizens or residing in a non-SHRS area were excluded from the study.

RESULTS

A total of 147,004 patients were included in the study, of which 7252 (4.9%) patients died during the study period. The mean age of patients was 50.2 ± 17.2 years old and 7.1% (n = 10,400) of patients stayed in public rental housing. Patients who passed away had higher utilization of healthcare resources in the past 1 year and a higher proportion stayed in public rental housing (p < 0.001). They also had higher rates of co-morbidities such as hypertension, hyperlipidaemia and diabetes. (p < 0.001) After adjustment for demographic and clinical covariates, residence in public rental housing was associated with increased risk of all-cause mortality (Adjusted hazard ratio: 1.568, 95% CI: 1.469-1.673).

CONCLUSION

Public rental housing was an independent risk factor for all-cause mortality. More studies should be conducted to understand health-seeking behavior and needs of public rental housing patients, to aid policymakers in formulating better plans for improving their health outcomes.

Effectiveness of a chronic obstructive pulmonary disease integrated care pathway in a regional health system: a propensity score matched cohort study

OBJECTIVE

The chronic obstructive pulmonary disease (COPD) integrated care pathway (ICP) programme was designed and implemented to ensure that the care for patients with COPD is comprehensive and integrated across different care settings from primary care to acute hospital and home. We evaluated the effectiveness of the ICP programme for patients with COPD.

DESIGN, SETTING AND PARTICIPANTS

A retrospective propensity score matched cohort study was conducted comparing differences between programme enrolees and propensity-matched non-enrolees in a Regional Health System in Singapore. Data on patients diagnosed with COPD who enrolled in the programme (n=95) and patients who did not enrol (n=6330) were extracted from the COPD registry and hospital administrative databases. Enrolees and non-enrolees were propensity score matched.

OUTCOME MEASURES

The risk of COPD hospitalisations and COPD hospital bed days savings were compared between the groups using a difference-in-difference strategy and generalised estimating equation approach. Adherence with recommended care elements for the COPD-ICP group was measured quarterly at baseline and during a 2-year follow-up period.

RESULTS

Compared with non-enrolees, COPD hospitalisation risk for ICP programme enrolees was significantly lower in year 2 (incidence rate ratio (IRR): 0.73; 95% CI 0.54 to 1.00). Similarly, COPD hospital bed days was significantly lower for enrolees in year 2 (IRR: 0.78; 95% CI 0.64 to 0.95). ICP programme patients had sustained improvements in compliance with all recommended care elements for patients with COPD. The overall all-or-none care bundle compliance rate had improved from 28% to 54%.

CONCLUSION

The study concluded that the COPD-ICP programme was associated with reductions in COPD hospitalisation risk and COPD health utilisation in a 2-year follow-up period.

Evaluation of a practical expert defined approach to patient population segmentation: a case study in Singapore

Background

Segmenting the population into groups that are relatively homogeneous in healthcare characteristics or needs is crucial to facilitate integrated care and resource planning. We aimed to evaluate the feasibility of segmenting the population into discrete, non-overlapping groups using a practical expert and literature driven approach. We hypothesized that this approach is feasible utilizing the electronic health record (EHR) in SingHealth.

Methods

In addition to well-defined segments of “Mostly healthy”, “Serious acute illness but curable” and “End of life” segments that are also present in the Ministry of Health Singapore framework, patients with chronic diseases were segmented into “Stable chronic disease”, “Complex chronic diseases without frequent hospital admissions”, and “Complex chronic diseases with frequent hospital admissions”. Using the electronic health record (EHR), we applied this framework to all adult patients who had a healthcare encounter in the Singapore Health Services Regional Health System in 2012. ICD-9, 10 and polyclinic codes were used to define chronic diseases with a comprehensive look-back period of 5 years. Outcomes (hospital admissions, emergency attendances, specialist outpatient clinic attendances and mortality) were analyzed for years 2012 to 2015.

Results

Eight hundred twenty five thousand eight hundred seventy four patients were included in this study with the majority being healthy without chronic diseases. The most common chronic disease was hypertension. Patients with “complex chronic disease” with frequent hospital admissions segment represented 0.6% of the eligible population, but accounted for the highest hospital admissions (4.33 ± 2.12 admissions; p < 0.001) and emergency attendances (ED) (3.21 ± 3.16 ED visits; p < 0.001) per patient, and a high mortality rate (16%). Patients with metastatic disease accounted for the highest specialist outpatient clinic attendances (27.48 ± 23.68 visits; p < 0.001) per patient despite their relatively shorter course of illness and high one-year mortality rate (33%).

Conclusion

This practical segmentation framework can potentially distinguish among groups of patients, and highlighted the high disease burden of patients with chronic diseases. Further research to validate this approach of population segmentation is needed.

Electronic supplementary material

The online version of this article (doi: 10.1186/s12913-017-2736-8) contains supplementary material, which is available to authorized users.

Performance of the LACE index to identify elderly patients at high risk for hospital readmission in Singapore

Unplanned readmissions may be avoided by accurate risk prediction and appropriate resources could be allocated to high risk patients. The Length of stay, Acuity of admission, Charlson comorbidity index, Emergency department visits in past six months (LACE) index was developed to predict hospital readmissions in Canada. In this study, we assessed the performance of the LACE index in a Singaporean cohort by identifying elderly patients at high risk of 30-day readmissions. We further investigated the use of additional risk factors in improving readmission prediction performance.Data were extracted from the hospital's electronic health records (EHR) for all elderly patients ≥ 65 years, with alive-discharge episodes from Singapore General Hospital in 2014. In addition to LACE, we also collected patients' data during the index admission, including demographics, medical history, laboratory results, and previous medical utilization.Among the 17,006 patients analyzed, 2051 or 12.1% of them were observed 30-day readmissions. The final predictive model was better than the LACE index in terms of discriminative ability; c-statistic of LACE index and final logistic regression model was 0.595 and 0.628, respectively.The LACE index had poor discriminative ability in identifying elderly patients at high risk of 30-day readmission, even if it was augmented with additional risk factors. Further studies should be conducted to discover additional factors that may enable more accurate and timely identification of patients at elevated risk of readmissions, so that necessary preventive actions can be taken.

FAM-FACE-SG: a score for risk stratification of frequent hospital admitters

Background

An accurate risk stratification tool is critical in identifying patients who are at high risk of frequent hospital readmissions. While 30-day hospital readmissions have been widely studied, there is increasing interest in identifying potential high-cost users or frequent hospital admitters. In this study, we aimed to derive and validate a risk stratification tool to predict frequent hospital admitters.

Methods

We conducted a retrospective cohort study using the readily available clinical and administrative data from the electronic health records of a tertiary hospital in Singapore. The primary outcome was chosen as three or more inpatient readmissions within 12 months of index discharge. We used univariable and multivariable logistic regression models to build a frequent hospital admission risk score (FAM-FACE-SG) by incorporating demographics, indicators of socioeconomic status, prior healthcare utilization, markers of acute illness burden and markers of chronic illness burden. We further validated the risk score on a separate dataset and compared its performance with the LACE index using the receiver operating characteristic analysis.

Results

Our study included 25,244 patients, with 70% randomly selected patients for risk score derivation and the remaining 30% for validation. Overall, 4,322 patients (17.1%) met the outcome. The final FAM-FACE-SG score consisted of nine components: Furosemide (Intravenous 40 mg and above during index admission); Admissions in past one year; Medifund (Required financial assistance); Frequent emergency department (ED) use (≥3 ED visits in 6 month before index admission); Anti-depressants in past one year; Charlson comorbidity index; End Stage Renal Failure on Dialysis; Subsidized ward stay; and Geriatric patient or not. In the experiments, the FAM-FACE-SG score had good discriminative ability with an area under the curve (AUC) of 0.839 (95% confidence interval [CI]: 0.825–0.853) for risk prediction of frequent hospital admission. In comparison, the LACE index only achieved an AUC of 0.761 (0.745–0.777).

Conclusions

The FAM-FACE-SG score shows strong potential for implementation to provide near real-time prediction of frequent admissions. It may serve as the first step to identify high risk patients to receive resource intensive interventions.

Characteristics and prognoses of patients treated by an anaesthesiologist-manned prehospital emergency care unit. A retrospective cohort study

OBJECTIVE

When planning and dimensioning an emergency medical system, knowledge of the population serviced is vital. The amount of literature concerning the prehospital population is sparse. In order to add to the current body of literature regarding prehospital treatment, thus aiding future public health planning, we describe the workload of a prehospital anaesthesiologist-manned mobile emergency care unit (MECU) and the total population it services in terms of factors associated with mortality.

PARTICIPANTS

The study is a register-based study investigating all missions carried out by a MECU operating in a mixed urban/rural area in Denmark from 1 May 2006 to 31 December 2014. Information on missions was extracted from the local MECU registry and linked at the individual level to the Danish population-based databases, the National Patient Registry and the Civil Registration System.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were number of missions and number of patient contacts. Secondary patient variables were mortality and association between mortality and age, sex, comorbidity, prior admission to hospital and response time.

RESULTS

The MECU completed 41 513 missions (mean 13.1 missions/day) having 32 873 patient contacts, corresponding to 19.2 missions and 15.2 patient encounters per 1000 patient years. Patient variables: the median age was 57 years (range 0-108 years), 42.8% (42.3% to 43.4%) were women. For patients admitted to hospital alive, 30-day mortality was 5.7% (5.4% to 6.0%); 90-day mortality was 8.1% (7.8% to 8.5%) while 2-year mortality was 16.4% (16.0% to 16.8%). Increasing age, male sex, comorbidity and prior admission to hospital but not response time were associated with mortality.

CONCLUSIONS

Mortality following an incident requiring the assistance of a MECU was high in the first 2 years following the incident. MECU response time assessed as a continuous parameter was not associated with patient outcome.